Textbook of Surgery Julian A.

Smith
Visit to download the full and correct content document:
https://textbookfull.com/product/textbook-of-surgery-julian-a-smith/
More products digital (pdf, epub, mobi) instant
download maybe you interests ...

Smith s Textbook of Endourology 2 Volume Set Arthur D.

Smith

https://textbookfull.com/product/smith-s-textbook-of-
endourology-2-volume-set-arthur-d-smith/

Oxford Textbook of Neurological Surgery Ramez Kirollos

https://textbookfull.com/product/oxford-textbook-of-neurological-
surgery-ramez-kirollos/

Sabiston Textbook of Surgery [Missing Pages ONLY]

Townsend

https://textbookfull.com/product/sabiston-textbook-of-surgery-
missing-pages-only-townsend/

Textbook of Endocrine Surgery 3rd Edition Orlo Clark

https://textbookfull.com/product/textbook-of-endocrine-
surgery-3rd-edition-orlo-clark/
Oxford Textbook of Urological Surgery Freddie C. Hamdy

https://textbookfull.com/product/oxford-textbook-of-urological-
surgery-freddie-c-hamdy/

Hinman’s Atlas of Urologic Surgery 4th Edition Joseph

Smith

https://textbookfull.com/product/hinmans-atlas-of-urologic-
surgery-4th-edition-joseph-smith/

The ASCRS Textbook of Colon and Rectal Surgery Hull

https://textbookfull.com/product/the-ascrs-textbook-of-colon-and-
rectal-surgery-hull/

PEDIATRIC SURGERY a comprehensive textbook for africa

2nd Edition Emmanuel A. Ameh

https://textbookfull.com/product/pediatric-surgery-a-
comprehensive-textbook-for-africa-2nd-edition-emmanuel-a-ameh/

Multiplatform Media in Mexico Growth and Change Since

2010 Paul Julian Smith

https://textbookfull.com/product/multiplatform-media-in-mexico-
growth-and-change-since-2010-paul-julian-smith/
Textbook of Surgery
Textbook of
Surgery
EDITED BY

Julian A. Smith
MBBS, MS, MSurgEd, FRACS, FACS, FFSTRCSEd, FCSANZ, FAICD
Head, Department of Surgery (School of Clinical Sciences at Monash Health), Monash University
Head, Department of Cardiothoracic Surgery, Monash Health
Editor‐in‐Chief, ANZ Journal of Surgery

Andrew H. Kaye AM
MBBS, MD, FRACS
Head, Department of Surgery, The University of Melbourne

Christopher Christophi AM
MBBS (Hons), MD, FRACS, FRCS, FACS
Head of Surgery (Austin Health), The University of Melbourne

Wendy A. Brown
MBBS (Hons), PhD, FRACS, FACS
Head, Department of Surgery (Central Clinical School, Alfred Health), Monash University
Director, Centre for Obesity Research and Education (CORE), Monash University

FOURTH EDITION
This edition first published 2020 © 2020 by John Wiley & Sons Ltd
Edition History
1e (1997); 2e (2001); 3e (2006) Blackwell Publishing Ltd.
All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted, in any
form or by any means, electronic, mechanical, photocopying, recording or otherwise, except as permitted by law. Advice
on how to obtain permission to reuse material from this title is available at http://www.wiley.com/go/permissions.
The right of Julian A. Smith, Andrew H. Kaye, Christopher Christophi and Wendy A. Brown to be identified as the
authors of the editorial material in this work has been asserted in accordance with law.
Registered Offices
John Wiley & Sons, Inc., 111 River Street, Hoboken, NJ 07030, USA
John Wiley & Sons Ltd, The Atrium, Southern Gate, Chichester, West Sussex, PO19 8SQ, UK
Editorial Office
9600 Garsington Road, Oxford, OX4 2DQ, UK
For details of our global editorial offices, customer services, and more information about Wiley products visit us at
www.wiley.com.
Wiley also publishes its books in a variety of electronic formats and by print‐on‐demand. Some content that appears in
standard print versions of this book may not be available in other formats.
Limit of Liability/Disclaimer of Warranty
The contents of this work are intended to further general scientific research, understanding, and discussion only and are
not intended and should not be relied upon as recommending or promoting scientific method, diagnosis, or treatment
by physicians for any particular patient. In view of ongoing research, equipment modifications, changes in governmental
regulations, and the constant flow of information relating to the use of medicines, equipment, and devices, the reader
is urged to review and evaluate the information provided in the package insert or instructions for each medicine,
equipment, or device for, among other things, any changes in the instructions or indication of usage and for added
warnings and precautions. While the publisher and authors have used their best efforts in preparing this work, they
make no representations or warranties with respect to the accuracy or completeness of the contents of this work and
specifically disclaim all warranties, including without limitation any implied warranties of merchantability or fitness
for a particular purpose. No warranty may be created or extended by sales representatives, written sales materials or
promotional statements for this work. The fact that an organization, website, or product is referred to in this work
as a citation and/or potential source of further information does not mean that the publisher and authors endorse the
information or services the organization, website, or product may provide or recommendations it may make. This
work is sold with the understanding that the publisher is not engaged in rendering professional services. The advice
and strategies contained herein may not be suitable for your situation. You should consult with a specialist where
appropriate. Further, readers should be aware that websites listed in this work may have changed or disappeared between
when this work was written and when it is read. Neither the publisher nor authors shall be liable for any loss of profit or
any other commercial damages, including but not limited to special, incidental, consequential, or other damages.
Library of Congress Cataloging‐in‐Publication Data
Names: Smith, Julian A., editor. | Kaye, Andrew H., 1950– editor.
Title: Textbook of surgery / edited by Julian A. Smith, MBBS, MS, MSurgEd, FRACS, FACS, FFSTRCSEd, FCSANZ,
FAICD Head, Department of Surgery (School of Clinical Sciences at Monash Health), Monash University, Head,
Department of Cardiothoracic Surgery, Monash Health, Editor-in-Chief, ANZ Journal of Surgery, Andrew H. Kaye,
AM, MBBS, MD, FRACS, Head, Department of Surgery, The University of Melbourne, Christopher Christophi, AM,
MBBS (Hons), MD, FRACS, FRCS, FACS, Head of Surgery (Austin Health), The University of Melbourne, Wendy A.
Brown, MBBS (Hons), PhD, FRACS, FACS, Head, Department of Surgery (Central Clinical School, Alfred Health),
Monash University Director, Centre for Obesity Research and Education (CORE), Monash University.
Other titles: Surgery
Description: Fourth edition. | Hoboken, NJ : Wiley-Blackwell, 2020. | Includes bibliographical references and index.
Identifiers: LCCN 2019030070 (print) | LCCN 2019030071 (ebook) | ISBN 9781119468080 (paperback) |
ISBN 9781119468172 (adobe pdf) | ISBN 9781119468165 (epub)
Subjects: LCSH: Surgery.
Classification: LCC RD31 .T472 2020 (print) | LCC RD31 (ebook) | DDC 617–dc23
LC record available at https://lccn.loc.gov/2019030070
LC ebook record available at https://lccn.loc.gov/2019030071
Cover image: © gchutka/Getty Images
Cover design by Wiley
Set in 9/11.5pt Sabon by SPi Global, Pondicherry, India

10 9 8 7 6 5 4 3 2 1
 Contents
Contributors, viii
Preface, xiii
Acknowledgements, xiv
Section 1 Principles of Surgery
1 Preoperative management, 3
Julian A. Smith
2 Assessment of surgical risk, 13
Benjamin N.J. Thomson
3 Anaesthesia and pain medicine, 19
David Story
4 Postoperative management, 25
Peter Devitt
5 Surgical techniques, 35
Benjamin N.J. Thomson and David M.A. Francis
6 Management of surgical wounds, 45
Rodney T. Judson
7 Nutrition and the surgical patient, 49
William R.G. Perry and Andrew G. Hill
8 Care of the critically ill patient, 57
Jeffrey J. Presneill, Christopher MacIsaac
and John F. Cade
9 Surgical infection, 65
Marcos V. Perini and Vijayaragavan
Muralidharan
10 Transplantation surgery, 75
Michael A. Fink
11 Principles of surgical oncology, 87
G. Bruce Mann and Robert J.S. Thomas
12 Introduction to the operating theatre, 93
Andrew Danks, Alan C. Saunder
and Julian A. Smith
13 Emergency general surgery, 109
Benjamin N.J. Thomson and Rose Shakerian
Section 2 Upper Gastrointestinal Surgery
14 Gastro‐oesophageal reflux disease and hiatus
hernias, 115
Paul Burton and Geraldine J. Ooi
15 Tumours of the oesophagus, 123
Ahmad Aly and Jonathan Foo
16 Peptic ulcer disease, 133
Paul A. Cashin and S.C. Sydney Chung
17 Gastric neoplasms, 143
John Spillane
18 Obesity and bariatric surgery, 151
Yazmin Johari and Wendy A. Brown
Section 3 Hepatopancreaticobiliary Surgery
19 Gallstones, 163
Arthur J. Richardson
20 Malignant diseases of the hepatobiliary
system, 173
Thomas J. Hugh and Nigel B. Jamieson
21 Liver infections, 191
Vijayaragavan Muralidharan, Marcos V. Perini
and Christopher Christophi
22 Pancreatitis, 199
Peter S. Russell and John A. Windsor
23 Pancreatic tumours, 209
David Burnett and Mehrdad Nikfarjam
24 Portal hypertension and surgery on the patient
with cirrhosis, 219
Michael A. Fink
Section 4 Lower Gastrointestinal Surgery
25 Principles of colorectal and small bowel
surgery, 229
Ian Hayes
26 Physiology of small and large bowel: alterations
due to surgery and disease, 237
Jacob McCormick and Ian Hayes
27 Small bowel obstruction and ischaemia, 243
Ian Hayes and the late Joe J. Tjandra
28 The appendix and Meckel’s diverticulum, 249
Rose Shakerian and the late Joe J. Tjandra
29 Inflammatory bowel disease, 255
Susan Shedda, Brit Christensen and
the late Joe J. Tjandra
30 Diverticular disease of the colon, 267
Ian Hastie and the late Joe J. Tjandra
31 Colorectal cancer, 273
Ian T. Jones and the late Joe J. Tjandra
v
vi Contents

32 Large bowel obstruction, 285 Section 11 Orthopaedic Surgery

Raaj Chandra 50 Fractures and dislocations, 457
33 Perianal disorders I: excluding sepsis, 293 Peter F. Choong
Ian Hayes and Susan Shedda 51 Diseases of bone and joints, 465
34 Perianal disorders II: sepsis, 301 Peter F. Choong
Ian Hayes and the late Joe J. Tjandra
Section 12 Neurosurgery
Section 5 Breast Surgery 52 Head injuries, 483
35 Breast assessment and benign breast Andrew H. Kaye
disease, 309 53 Intracranial tumours, infection and
Rajiv V. Dave and G. Bruce Mann aneurysms, 493
36 Malignant breast disease and surgery, 317 Andrew H. Kaye
Rajiv V. Dave and G. Bruce Mann 54 Nerve injuries, peripheral nerve entrapments
and spinal cord compression, 511
Section 6 Endocrine Surgery Andrew H. Kaye
37 Thyroid, 331
Jonathan Serpell Section 13 Vascular Surgery
38 Parathyroid, 339 55 Disorders of the arterial system, 527
Jonathan Serpell Raffi Qasabian and Gurfateh
39 Tumours of the adrenal gland, 345 Singh Sandhu
Jonathan Serpell 56 Extracranial vascular disease, 537
Raffi Qasabian and Gurfateh Singh Sandhu
Section 7 Head and Neck Surgery 57 Venous and lymphatic diseases
40 Eye injuries and infections, 353 of the limbs, 545
Helen V. Danesh‐Meyer Hani Saeed and Michael J. Grigg
41 Otorhinolaryngology, 359 58 Endovascular therapies, 553
Stephen O’Leary and Neil Vallance Timothy Buckenham
42 Tumours of the head and neck, 369
Rodney T. Judson Section 14 Urology
59 Benign urological conditions, 565
Section 8 Hernias Anthony J. Costello, Daniel M. Costello and
43 Hernias, 381 Fairleigh Reeves
Roger Berry and David M.A. Francis 60 Genitourinary oncology, 577
Homayoun Zargar and Anthony J. Costello
Section 9 Skin and Soft Tissues
44 Tumours and cysts of the skin, 397 Section 15 Cardiothoracic Surgery
Rodney T. Judson 61 Principles and practice of cardiac surgery, 587
45 Soft tissue tumours, 403 James Tatoulis and Julian A. Smith
Peter F. Choong 62 Common topics in thoracic surgery, 603
46 Infection of the extremities, 415 Julian A. Smith
Mark W. Ashton and David M.A. Francis
47 Principles of plastic surgery, 423 Section 16 Problem Solving
Mark W. Ashton 63 Chronic constipation, 617
Kurvi Patwala and Peter De Cruz
Section 10 Trauma 64 Faecal incontinence, 625
48 Principles of trauma management, 431 Andrew Bui
Scott K. D’Amours, Stephen A. Deane and 65 Rectal bleeding, 633
Valerie B. Malka Adele Burgess
49 Burns, 443 66 Haematemesis and melaena, 637
Ioana Tichil and Heather Cleland Wendy A. Brown
 Contents vii

67 Obstructive jaundice, 643 76 Massive haemoptysis, 707

Frederick Huynh and Val Usatoff Julian A. Smith
68 The acute abdomen, peritonitis and 77 Epistaxis, 711
­intra‐abdominal abscesses, 649 Robert J.S. Briggs
Paul Cashin, Michael Levitt and 78 Low back and leg pain, 715
the late Joe J. Tjandra Jin W. Tee and Jeffrey V. Rosenfeld
69 Ascites, 659 79 Acute scrotal pain, 727
David A.K. Watters, Sonal Nagra and Anthony Dat and Shomik Sengupta
David M.A. Francis 80 Post‐traumatic confusion, 735
70 Neck swellings, 667 John Laidlaw
Rodney T. Judson 81 Sudden‐onset severe headache, 745
71 Acute airway problems, 675 Alexios A. Adamides
Stephen O’Leary 82 The red eye, 749
72 Dysphagia, 679 Christine Chen
Wendy A. Brown 83 Double vision, 757
73 Leg swelling and ulcers, 685 Christine Chen
Alan C. Saunder, Steven T.F. Chan and
David M.A. Francis Answers to MCQs, 763
74 Haematuria, 693 Index, 767
Kenny Rao and Shomik Sengupta
75 Postoperative complications, 699
Peter Devitt
 Contributors
Alexios A. Adamides
BMedSci, BMBS, MRCS (Edin), MD, FRACS
Clinical Senior Lecturer, University of Melbourne
Neurosurgeon, Royal Melbourne Hospital
Melbourne, Victoria, Australia
Ahmad Aly
MBBS, MS, FRACS
Clinical Associate Professor of Surgery, University of
Melbourne
Head, Upper Gastrointestinal Surgery, Austin Health
Melbourne, Victoria, Australia
Mark W. Ashton
MBBS, MD, FRACS
Clinical Professor of Surgery, University of Melbourne
Plastic Surgeon, Royal Melbourne Hospital
Melbourne, Victoria, Australia
Roger Berry
MBBS, FRACS
Senior Lecturer in Surgery, Monash University
Upper Gastrointestinal and Hepatobiliary Surgeon,
Monash Health
Melbourne, Victoria, Australia
Robert J.S. Briggs
MBBS, FRACS, FACS
Clinical Professor of Surgery, University of Melbourne
Clinical Executive Director of Otolaryngology; Head,
Otology and Medical Director, Cochlear Implant Clinic,
Royal Victorian Eye and Ear Hospital
Melbourne, Victoria, Australia
Wendy A. Brown
MBBS (Hons), PhD, FRACS, FACS
Head, Department of Surgery (Central Clinical School,
Alfred Health), Monash University
Director, Centre for Obesity Research and Education
(CORE), Monash University
Melbourne, Victoria, Australia
Timothy Buckenham
MBChB, FRANZCR, FRCR, FCIRSE, EBIR
Professor of Vascular Imaging and Intervention, Monash
University
Head, Vascular Services, Department of Imaging,
Monash Health
Melbourne, Victoria, Australia
viii
Andrew Bui
MBBS, MSc, FRACS
Lecturer in Surgery, University of Melbourne
Colorectal Surgeon, Austin Health
Melbourne, Victoria, Australia
Adele Burgess
BMedSci (Hons), MBBS, FRACS
Senior Lecturer in Surgery, University of Melbourne
Head, Colorectal Surgery, Austin Health
Melbourne, Victoria, Australia
David Burnett
BSc, MBBS, FRACS
Hepatopancreaticobiliary Surgeon
John Hunter Hospital
Newcastle, New South Wales, Australia
Paul Burton
MBBS(Hons), PhD, FRACS
Senior Lecturer in Surgery, Monash University
Upper Gastrointestinal Surgeon, Alfred Health
Melbourne, Victoria, Australia
John F. Cade AM
MD, PhD, FRACP, FANZCA, FCICM
Professorial Fellow, Department of Medicine, University
of Melbourne
Emeritus Consultant in Intensive Care, Royal Melbourne
Hospital
Melbourne, Victoria, Australia
Paul A. Cashin
MBBS, FRACS
Clinical Associate Professor of Surgery, Monash
University
Director of General Surgery, Monash Health
Melbourne, Victoria, Australia
Steven T.F. Chan
MBBS, PhD, FRACS
Professor of Surgery, University of Melbourne
Upper Gastrointestinal Surgeon, Western Health
Melbourne, Victoria, Australia
Raaj Chandra
MBBS, BMed Sci, MEd, FRACS
Adjunct Senior Lecturer in Surgery, Monash University
Colorectal Surgeon, Royal Melbourne Hospital
Melbourne, Victoria, Australia
 Contributors ix

Christine Chen Andrew Danks

MBBS, PhD, FRANZCO MBBS, MD, FRACS
Clinical Associate Professor of Surgery, Monash University Associate Professor of Surgery, Monash University
Head, Department of Ophthalmology, Monash Health Head, Department of Neurosurgery, Monash Health
Melbourne, Victoria, Australia Melbourne, Victoria, Australia

Peter F. Choong Anthony Dat

MBBS, MD, FRACS, FAOrthA, FAAHMS MBBS, MS
Professor of Surgery, University of Melbourne Urology Registrar, Eastern Health
Director of Orthopaedics, St. Vincent’s Hospital Melbourne, Victoria, Australia
Chair, Bone and Soft Tissue Sarcoma Service
Peter MacCallum Cancer Centre Rajiv V. Dave
Melbourne, Victoria, Australia MBChB, FRCSEd, MD, BSc(Hons)
Fellow in Oncoplastic Breast and Endocrine Surgery,
Britt Christensen Royal Melbourne Hospital
BSc, MBBS(Hons), MPH, FRACP Melbourne, Victoria, Australia
Head, Inflammatory Bowel Disease Unit, Department of The Nightingale Centre, Manchester University NHS
Gastroenterology, Royal Melbourne Hospital Foundation Trust
Melbourne, Victoria, Australia Manchester, UK

Christopher Christophi AM Stephen A. Deane AM

MBBS, FRACS, FACS, FRCSC, FRCSEd (ad hom),
MBBS (Hons), MD, FRACS, FRCS, FACS
FRCSThailand (Hon)
Head of Surgery (Austin Health), University of
Associate Dean, Clinical Partnerships, Macquarie
Melbourne
University, Sydney
Melbourne, Victoria, Australia
Conjoint Professor of Surgery, University of Newcastle
Honorary Consultant Surgeon, Hunter and New
S.C. Sydney Chung
England Local Health District
MD, FRCS (Edin), FRCP (Edin)
New South Wales, Australia
Formerly Dean, Faculty of Medicine, Chinese University
of Hong Kong Peter De Cruz
Senior Consultant in Surgery, Union Hospital MBBS, PhD, FRACP
Hong Kong Senior Lecturer in Medicine, University of Melbourne
Gastroenterologist and Director, Inflammatory Bowel
Heather Cleland Disease Service, Austin Health
MBBS, FRACS Melbourne, Victoria, Australia
Director, Victorian Adult Burns Service and Plastic
Surgeon, Alfred Health Peter Devitt
Melbourne, Victoria, Australia MBBS, MS, FRCS, FRACS
Associate Professor of Surgery, University of Adelaide
Anthony J. Costello AM General and Upper Gastrointestinal Surgeon, Royal
MBBS, MD, FRACS, FRCSI (Hon) Adelaide Hospital
Professorial Fellow, University of Melbourne Adelaide, South Australia, Australia
Head, Department of Urology, Royal Melbourne Hospital
Melbourne, Victoria, Australia Michael A. Fink
MBBS, MD, FRACS
Daniel M. Costello Senior Lecturer in Surgery, University of Melbourne
MBBS, DipSurgAnat Hepatopancreatobiliary and Liver Transplant Surgeon,
Surgical Resident, St. Vincent’s Hospital Austin Health
Melbourne, Victoria, Australia Melbourne, Victoria, Australia

Scott K. D’Amours Jonathan Foo

BSc, MDCM, FRCSC, FRACS, FRCS(Glasg), FACS MBChB, DipGrad(Arts), PhD, FRACS
Conjoint Senior Lecturer in Surgery, University of New Upper Gastrointestinal Surgery Fellow, Austin Health
South Wales Melbourne, Victoria, Australia
Director, Department of Trauma Services, Liverpool
Hospital David M.A. Francis
Sydney, New South Wales, Australia BSc (Med Sci), MS, MD, PhD (Arts), FRCS (Eng), FRCS
(Edin), FRACS
Helen V. Danesh‐Meyer Renal Transplant Surgeon, Department of Urology, Royal
MBChB, MD, PhD, FRANZCO Children’s Hospital, Melbourne, Victoria, Australia
Professor of Ophthalmology, School of Medicine, Visiting Professor of Surgery and Renal Transplant
University of Auckland Surgeon, Department of Surgery, Tribhuvan University
Auckland, New Zealand Teaching Hospital, Kathmandu, Nepal
x Contributors
Michael J. Grigg
AM, MBBS, FRACS
Professor of Surgery, Monash University
Director of Surgery, Eastern Health
Melbourne, Victoria, Australia
Ian Hastie
MBBS, FRACS
Senior Lecturer in Surgery, University of Melbourne
Colorectal Surgeon, Royal Melbourne Hospital
Melbourne, Victoria, Australia
Ian Hayes
MBBS, MS, MEpi, FRCS(Gen Surg), FRACS
Clinical Associate Professor of Surgery, University of
Melbourne
Head, Colorectal Surgery Unit, Royal Melbourne
Hospital
Melbourne, Victoria, Australia
Andrew G. Hill
MBChB, MD, EdD, FRACS, FACS
Professor of Surgery, University of Auckland
Colorectal Surgeon, Middlemore Hospital
Auckland, New Zealand
Thomas J. Hugh
MD, FRACS
Professor of Surgery, University of Sydney
Head, Upper Gastrointestinal Surgery Unit, Royal North
Shore Hospital
Sydney, New South Wales, Australia
Frederick Huynh
BSc(Hons), MBBS(Hons), FRACS
ANZHPBA Fellow, Alfred Health
Melbourne, Victoria, Australia
Nigel B. Jamieson
MBChB, BSc(Hons), FRCS, PhD
Lecturer in Surgery and Cancer Research UK Clinician
Scientist, University of Glasgow
Honorary Consultant in HPB Surgery, Glasgow Royal
Infirmary
Glasgow, UK
Yazmin Johari
MBBS(Hons)
General Surgery Registrar, Alfred Health
Melbourne, Victoria, Australia
Ian T. Jones
MBBS, FRCS, FRACS, FASCRS
Clinical Professor of Surgery, University of Melbourne
Colorectal Surgeon, Royal Melbourne Hospital
Melbourne, Victoria, Australia
Rodney T. Judson
MBBS, FRACS, FRCS
Associate Professor of Surgery, University of Melbourne
Head of Trauma Service, Royal Melbourne Hospital
Melbourne, Victoria, Australia
Andrew H. Kaye AM
MBBS, MD, FRACS
Head, Department of Surgery, University of Melbourne
Neurosurgeon, Royal Melbourne Hospital
Melbourne, Victoria, Australia
John Laidlaw
MBBS, FRACS
Clinical Associate Professor of Surgery, University of
Melbourne
Neurosurgeon, Royal Melbourne Hospital
Melbourne, Victoria, Australia
Michael Levitt
MBBS, FRACS
Colorectal Surgeon, St. John of God Healthcare, Subiaco
Perth, Western Australia, Australia
Jacob McCormick
BMedSci, MBBS, FRACS
Colorectal Surgeon, Royal Melbourne Hospital and Peter
MacCallum Cancer Centre
Melbourne, Victoria, Australia
Christopher MacIsaac
MBBS (Hons), PhD, FRACP, FCICM
Associate Professor in Medicine
Director, Intensive Care Unit, Royal Melbourne Hospital
Melbourne, Victoria, Australia
Valerie B. Malka
MBBS, FRACS, MIPH, MA
Senior Lecturer in Surgery, University of New South Wales
General and Trauma Surgeon, Deputy Director of
Trauma, Liverpool Hospital
Sydney, New South Wales, Australia
G. Bruce Mann
MBBS, PhD, FRACS
Professor of Surgery, University of Melbourne
Director of Breast Tumour Stream, Victorian
Comprehensive Cancer Centre
Melbourne, Victoria, Australia
Vijayaragavan Muralidharan
BMedSci, MBBS (Hons), MSurgEd, PhD, FRACS
Associate Professor of Surgery, University of Melbourne
Hepatopancreatobiliary Surgeon, Austin Health
Melbourne, Victoria, Australia
Sonal Nagra
MBBS, MMed(Surg), FRACS
Senior Lecturer in Rural General Surgery
Deakin University
Consultant Surgeon, University Hospital Geelong
Geelong, Victoria, Australia
Mehrdad Nikfarjam
MD, PhD, FRACS
Associate Professor of Surgery, University of Melbourne
Hepatopancreatobiliary Surgeon, Austin Health
Melbourne, Victoria, Australia

Stephen O’Leary
MBBS, BMedSci, PhD, FRACS
Professor of Otolaryngology, University of Melbourne
Ear, Nose and Throat Surgeon, Royal Victorian Eye and
Ear Hospital
Melbourne, Victoria, Australia
Geraldine J. Ooi
MBBS, BMedSci (Hons)
Senior Registrar, Centre for Obesity Research and
Education (CORE), Monash University
Senior Registrar in General Surgery, Alfred Health
Melbourne, Victoria, Australia
Kurvi Patwala
MBBS(Hons)
General Medical Registrar, Austin Health
Melbourne, Victoria, Australia
Marcos V. Perini
MD, PhD, FRACS
Senior Lecturer in Surgery, University of Melbourne
Hepatopancreaticobiliary and Liver Transplant Surgeon,
Austin Health
Melbourne, Victoria, Australia
William R.G. Perry
BSc, MBChB, MPH, FRACS
Senior Clinical Fellow, Department of Colorectal Surgery,
Oxford University Hospitals NHS Foundation Trust
Oxford, UK
Jeffrey J. Presneill
MBBS(Hons), PhD, MBiostat, PGDipEcho, FRACP, FCICM
Associate Professor in Medicine
University of Melbourne
Deputy Director, Intensive Care Unit
Royal Melbourne Hospital
Melbourne, Victoria, Australia
Raffi Qasabian
BSc(Hons), MBBS(Hons), FRACS
Vascular and Endovascular Surgeon, Royal Prince Alfred
Hospital
Sydney, New South Wales, Australia
Kenny Rao
MBBS, MS
Urology Registrar, Eastern Health
Melbourne, Victoria, Australia
Fairleigh Reeves
MBBS (Hons), DipSurgAnat
Urology Registrar, Royal Melbourne Hospital
Melbourne, Victoria, Australia
Arthur J. Richardson
MBBS, DClinSurg, FRACS, FACS
Associate Professor of Surgery, University of Sydney
Head, Hepatopancreatobiliary Surgery, Westmead
Hospital
Sydney, New South Wales, Australia
Contributors xi
Jeffrey V. Rosenfeld AC, OBE
MBBS, MS, MD, FRACS, FRCS(Ed), FACS, IFAANS,
FRCS (Glasg, Hon), FCNST(Hon), FRCST(Hon),
FACTM, MRACMA
Director, Monash Institute of Medical Engineering
Senior Neurosurgeon, Alfred Health
Melbourne, Victoria, Australia
Peter S. Russell
BSc, PGDipSci, MBChB
Research Fellow, Department of Surgery, University of
Auckland
Auckland, New Zealand
Hani Saeed
MD, BPharm
Vascular Surgery Registrar, Eastern Health
Melbourne, Victoria, Australia
Gurfateh Singh Sandhu
BSc (Advanced), MBBS
Vascular Surgery Registrar, Royal Prince Alfred Hospital
Sydney, New South Wales, Australia
Alan C. Saunder
MBBS, FRACS
Senior Lecturer in Surgery, Monash University
Vascular and Transplant Surgeon and Medical
Director, Surgery and Interventional Services Program,
Monash Health
Melbourne, Victoria, Australia
Shomik Sengupta
MBBS, MS, MD, FRACS
Professor of Surgery, Monash University
Urologist, Eastern Health
Melbourne, Victoria, Australia
Jonathan Serpell
MBBS, MD, MEd, FRACS, FACS, FRCSEd (ad hom)
Professor of Surgery, Monash University
Director of General Surgery and Head, Breast, Endocrine
and General Surgery Unit, Alfred Health
Melbourne, Victoria, Australia
Rose Shakerian
MBBS, DMedSci, FRACS
General Surgeon, Royal Melbourne Hospital
Melbourne, Victoria, Australia
Susan Shedda
MBBS, MPH, FRACS
Colorectal Surgeon, Royal Melbourne Hospital and
Royal Women’s Hospital
Melbourne, Victoria, Australia
Julian A. Smith
MBBS, MS, MSurgEd, FRACS, FACS, FFSTRCSEd,
FCSANZ, FAICD
Head, Department of Surgery (School of Clinical
Sciences at Monash Health), Monash University
xii Contributors

Head, Department of Cardiothoracic Surgery, Ioana Tichil

Monash Health MD
Melbourne, Victoria, Australia Burns Fellow, Victorian Adult Burns Service, Alfred Health
Melbourne, Victoria, Australia
John Spillane
MBBS, FRACS Joe J. Tjandra (deceased)
Lecturer in Surgery, University of Melbourne MBBS, MD, FRACS, FRCS(Eng), FRCPS, FASCRS
Surgical Oncologist, Division of Cancer Surgery, Peter Formerly Associate Professor of Surgery, University of
MacCallum Cancer Centre Melbourne
Melbourne, Victoria, Australia Colorectal Surgeon and Surgical Oncologist, Royal
Melbourne Hospital
David Story Melbourne, Victoria, Australia
MBBS (Hons), MD, BMedSci (Hons), FANZCA
Chair of Anaesthesia, Centre for Integrated Critical Care, Val Usatoff
University of Melbourne MBBS(Hons), MHSM, FRACS, FCHSM
Melbourne, Victoria, Australia Associate Professor of Surgery, University of Melbourne
Head, Upper Gastrointestinal and
Hepatopancreatobiliary Surgery, Western Health
James Tatoulis AM
Melbourne, Victoria, Australia
MBBS, MS, MD, FRACS, FCSANZ
Professor of Cardiothoracic Surgery, University of
Melbourne
Neil Vallance
MBBS, FRACS
Director of Cardiothoracic Surgery, Royal Melbourne
Senior Lecturer in Surgery, Monash University
Hospital
Emeritus Head, Department of Otolaryngology, Head
Melbourne, Victoria, Australia
and Neck Surgery, Monash Health
Melbourne, Victoria, Australia
Jin W. Tee
BMSc, MBBS, MD, FRACS David A.K. Watters AM, OBE
Associate Professor of Surgery, Monash University BSc (Hons), ChM, FRCSEd, FRACS
Complex Spine and Neurosurgeon, Spine Oncology Professor of Surgery, Deakin University
Surgery, Alfred Health Alfred Deakin Professor of Surgery
Head, Spine and Neurotrauma, National Trauma Deakin University and Barwon Health
Research Institute General and Endocrine Surgeon
Melbourne, Victoria, Australia University Hospital Geelong
Geelong, Victoria, Australia
Robert J.S. Thomas OAM
MBBS, MS, FRACS, FRCS(Eng) John A. Windsor
Professorial Fellow and Special Advisor on Health, BSc, MBChB, MD, FRACS, FACS
University of Melbourne Professor of Surgery, University of Auckland
Melbourne, Victoria, Australia General, Pancreatobiliary, Gastro‐oesophageal and
Laparoscopic Surgeon, Auckland City Hospital
Benjamin N.J. Thomson Auckland, New Zealand
MBBS, DMedSci, FRACS, FACS
Clinical Associate Professor in Surgery, University of Homayoun Zargar
Melbourne MBChB, FRACS
Head, Department of General Surgical Specialties Senior Lecturer in Surgery, University of Melbourne
Royal Melbourne Hospital Urologist, Royal Melbourne Hospital
Melbourne, Victoria, Australia Melbourne, Victoria, Australia
 Preface
Medical students and trainees must possess an
understanding of basic surgical principles, a knowl-
edge of specific surgical conditions, be able to per-
form a few basic procedures and be part of a
multidisciplinary team that manages the patient in
totality. All students of surgery must also be aware
of the rapid developments in basic sciences and
technology and understand where these develop-
ments impinge on surgical practice.
The Textbook of Surgery is intended to supply
this information, which is especially relevant given
the current content of the surgical curriculum for
undergraduates. Each topic is written by an expert
in the field from his or her own wisdom and experi-
ence. All contributors have been carefully chosen
from the Australasian region for their authoritative
expertise and personal involvement in undergradu-
ate teaching and postgraduate training.
In this textbook we have approached surgery
from a practical viewpoint while emphasising the
relevance of basic surgical principles. We have
attempted to cover most aspects of general surgery
including its subspecialties and selected topics of
other surgical specialties, including cardiothoracic
surgery, neurosurgery, plastic surgery, ophthalmol-
ogy, orthopaedic surgery, otolaryngology/head and
neck surgery, urology and vascular surgery.
Principles that underlie the assessment, care and
treatment of surgical patients are outlined, followed
by sections on various surgical disorders. The final
section presents a practical problem‐solving approach
to the diagnosis and management of common surgi-
cal conditions. In clinical practice, patients present
with symptoms and signs to the surgeon who then
has to formulate care plans, using such a problem‐
solving approach. This textbook provides a good
grounding for students in surgical diseases, problems
and management. Apart from forming the core cur-
riculum for medical students, surgical trainees will
also find the Textbook of Surgery beneficial in their
studies and their practice.
The fourth edition of the Textbook of Surgery
includes new or extensively revised chapters on the
assessment of surgical risk, the management of sur-
gical wounds, introduction to the operating theatre,
emergency general surgery, obesity and bariatric
surgery, lower gastrointestinal surgery, endovascu-
lar therapies, benign urological conditions, genitou-
rinary oncology, sudden‐onset severe headache and
the red eye.
With ever‐expanding medical knowledge, a core
amount of instructive and up‐to‐date information
is presented in a concise fashion. Important leading
references of classic publications or up‐to‐date
­literature have been provided for further reading. It
is our aim that this textbook will stimulate students
to refer to appropriate reviews and publications for
additional details on specific subjects.
We have presented the textbook in an attractive
and easily readable format by extensive use of
tables, boxes and illustrations. We hope that this
fourth edition will continue to be valuable to
undergraduate, graduate and postgraduate stu-
dents of surgery, and for general practitioners and
physicians as a useful summary of contemporary
surgery.
Julian A. Smith
Andrew H. Kaye
Christopher Christophi
Wendy A. Brown
Melbourne, Australia
xiii
 Acknowledgements
This book owes its existence to the contributions of
our talented surgeons and physicians from through-
out Australia, New Zealand and Asia. We are
indebted to the staff of Wiley in Australia (Simon
Goudie) and in Oxford (Claire Bonnett, Jennifer
Seward, Deirdre Barry and Nick Morgan) for their
support and diligence. We thank Associate Professor
David Francis, Mr Alan Cuthbertson and Professor
Robert Thomas for their assistance with previous
editions, which laid the foundation for this fourth
edition.
Our patients, students, trainees and surgical men-
tors have all been an inspiration to us, but above all
xiv
we owe a debt of gratitude to our loving families,
specifically our spouses and partners – Sally Smith,
Judy Kaye, Helena Fisher and Andrew Cook – as it
was precious time spent away from them which
allowed completion of this textbook.
The editors wish to dedicate this edition to two
highly esteemed previous editors, the late Joe
J. Tjandra and the late Gordon J.A. Clunie. Both
were inspirational surgical educators who left an
enduring legacy amongst the many students, train-
ees and colleagues with whom they interacted over
many years.
Section 1
Principles of Surgery
1 Preoperative management
Julian A. Smith
Department of Surgery (School of Clinical Sciences at Monash Health), Monash University
and Department of Cardiothoracic Surgery, Monash Health, Clayton, Victoria, Australia

act of placing a signature on a form. That signature

Introduction in itself is only meaningful if the patient has been
through a reasonable process that has left them in a
This chapter covers care of the patient from the
position to make an informed decision.
time the patient is considered for surgery through
There has been much written around issues of
to immediately prior to operation and deals with
informed consent, and the medico‐legal climate has
important generic issues relating to the care of all
changed substantially in the past decade. It is
surgical patients. Whilst individual procedures each
important for any doctor to have an understanding
have unique aspects to them, a sound working
of what is currently understood by informed con-
understanding of the common issues involved in
sent. Although the legal systems in individual juris-
preoperative care is critical to good patient out-
dictions may differ with respect to medical
comes. The important elements of preoperative
negligence, the standards around what constitutes
management are as follows.
informed consent are very similar.
• History taking: the present surgical condition
Until relatively recently, the standard applied to
and a general medical review.
deciding whether the patient was given adequate and
• Physical examination: the present surgical condi-
appropriate information with which to make a deci-
tion and a general examination.
sion was the so‐called Bolam test – practitioners are
• Reviewing available diagnostic investigations.
not negligent if they act in accordance with practice
• Ordering further diagnostic and screening
accepted by a reasonable body of medical opinion.
investigations.
Recent case law from both Australia and overseas
• Investigating and managing known or discovered
has seen a move away from that position. Although
medical conditions.
this area is complex, the general opinion is that a doc-
• Obtaining informed consent.
tor has a duty to disclose to a patient any material
• Scheduling the operation and any special prepa-
risks. A risk is said to be material if ‘in the circum-
rations (e.g. equipment required).
stances of that particular case, a reasonable person in
• Requesting an anaesthetic review.
the patient’s position, if warned of the risk would be
• Marking the operative site/side.
likely to attach significance to it or the medical prac-
• Prescribing any ongoing medications and proph-
titioner is, or should reasonably be aware that the
ylaxis against surgical site infection and deep
particular patient, if warned of the risk would attach
venous thrombosis.
significance to it’. It is important that this standard
• Planning postoperative recovery and possibly
relates to what a person in the patient’s position
rehabilitation.
would do and not just any reasonable person.
Important factors when considering the kinds
of information to disclose to patients include the
Informed consent following.
• The nature of the potential risks: more common
Although often thought of in a purely medico‐legal and more serious risks require disclosure.
way, the process of ensuring that a patient is • The nature of the proposed procedure: complex
informed about the procedure they are about to interventions require more information as do
undergo is a fundamental part of good‐quality procedures when the patient has no symptoms or
patient care. Informed consent is far more than the illness.

Textbook of Surgery, Fourth Edition. Edited by Julian A. Smith, Andrew H. Kaye, Christopher Christophi and Wendy A. Brown.
© 2020 John Wiley & Sons Ltd. Published 2020 by John Wiley & Sons Ltd.
3
4 Principles of Surgery
• The patient’s desire for information: patients
who ask questions make known their desire for
information and they should be told.
• The temperament and health of the patient: anx-
ious patients and patients with health problems or
other relevant circumstances that make a risk more
important for them may need more information.
• The general surrounding circumstances: the
information required for elective procedures
might be different from that required in those
conducted emergently.
Verbal discussions concerning the therapeutic
options, potential benefits and risks along with
common complications are often supplemented
with procedure‐specific patient explanatory bro-
chures. These provide a straightforward illustrated
account for the patient and their relatives to con-
sider and may be a source of clarification and/or
further questions about the proposed operation.
What does this mean for a medical practitioner?
Firstly, you must have an understanding of the legal
framework and standards. Secondly, you must docu-
ment how appropriate information was given to
patients – always write it down. If discussion points
are not documented, it may be argued that they
never occurred. On this point, whilst explanatory
brochures can be a very useful addition to the p­ rocess
of informed consent they do not remove the need to
undertake open conversations with the patient.
Doctors often see the process of obtaining
informed consent as difficult and complex, and this
view is leant support by changing standards.
However, the principles are relatively clear and not
only benefit patients but their doctors as well. A fully
informed patient is much more likely to adapt to the
demands of a surgical intervention, and should a
complication occur, they and their relatives almost
invariably accept such misfortune far more readily.
Preoperative assessment
The appropriate assessment of patients prior to sur-
gery to identify coexisting medical problems and to
plan perioperative care is of increasing importance.
Modern trends towards the increasing use of day‐
of‐surgery admission even for major procedures
have increased the need for careful and systematic
preoperative assessment, much of which occurs in a
pre‐admission clinic (PAC).
The goals of preoperative assessment are:
• To identify important medical issues in order to
◦◦ optimise their treatment
◦◦ inform the patient of additional risks associ-
ated with surgery
◦◦ ensure care is provided in an appropriate
environment.
• To identify important social issues which may
have a bearing on the planned procedure and the
recovery period.
• To familiarise the patient with the planned proce-
dure and the hospital processes.
Clearly the preoperative evaluation should include
a careful history and physical examination, together
with structured questions related to the planned
procedure. Simple questions related to exercise
­tolerance (such as ‘Can you climb a flight of stairs
without being short of breath?’) will often yield as
much useful information as complex tests of cardi-
orespiratory reserve. The clinical evaluation will
be coupled with a number of blood and radio-
logical tests. There is considerable debate as to the
value of many of the routine tests performed, and
each hospital will have its own protocol for such
evaluations.
Common patient observations, investigations
and screening tests prior to surgery include:
• vital signs (blood pressure, pulse rate, respiratory
rate, temperature) and pulse oximetry
• body weight
• urinalysis
• full blood examination and platelet count
• urea and electrolytes, blood sugar, tests of liver
function
• blood grouping and screen for irregular antibod-
ies (‘group and hold’)
• tests of coagulation, i.e. international normalised
ratio (INR) and activated partial thromboplastin
time (APTT)
• chest X‐ray
• electrocardiogram (ECG).
On the basis of the outcomes of this preoperative
evaluation a number of risk stratification systems
have been proposed. One in widespread daily use is
the relatively simple ASA (American Society of
Anesthesiologists) system (see Chapter 3, Table 3.3).
The preoperative assessment and work‐up will
be guided by a combination of the nature of the
operation proposed and the overall ‘fitness’ of the
patient. Whilst there are a number of ways of look-
ing at the type of surgery proposed, a simple three‐
way classification has much to commend it.
• Low risk: poses minimal physiological stress and
risk to the patient, and rarely requires blood
transfusion, invasive monitoring or intensive
care. Examples of such procedures would be
groin hernia repair, cataract surgery and
arthroscopy.
• Medium risk: moderate physiological stress
(fluid shifts, cardiorespiratory effects) and risk.

Usually associated with minimal blood loss.
Potential for significant problems must be appre-
ciated. Examples would be laparoscopic chole-
cystectomy, hysterectomy and hip replacement.
• High risk: significant perioperative physiological
stress. Often requires blood transfusion or infu-
sion of large fluid volumes. Requires invasive
monitoring and will often need intensive care.
Examples would be aortic surgery, major gastro-
intestinal resections and thoracic surgery.
A low‐risk patient (ASA I or II) will clearly require
a far less intensive work‐up than a high‐risk patient
(ASA III or IV) undergoing a high‐risk operation.
Areas of specific relevance to perioperative care
are cardiac disease and respiratory disease. It is
important that pre‐existing cardiorespiratory dis-
ease is optimised prior to surgery to minimise the
risk of complications. Patients with cardiac disease
can be stratified using a number of systems (New
York Heart Association Functional Class for angina
or heart failure; Goldman or Detsky indices) and
this stratification can be used to guide work‐up and
interventions and provide a guide to prognosis.
One of the most important respiratory factors is
whether the patient is a smoker. There is now clear
evidence that stopping smoking for at least 4 weeks
prior to surgery significantly reduces the risk of res-
piratory specific or generic complications.
Evaluation of the healthy patient
Patients with no clinically detectable systemic illnesses
except their surgical problem are classified into
ASA class I. Mortality for low‐risk surgical proce-
dures in this group is very low and complications
are likely to be due to technical errors. The mortality
for major high‐risk surgical procedures in such
patients is also low, of the order of a few per cent.
All such patients require detailed systems review
by history and physical examination prior to the
operation. Preoperative special tests may be added in
order to detect any subclinical disease that may
adversely affect surgery and to provide baseline val-
ues for comparison in the event of postoperative
complications. These tests should be sufficiently sen-
sitive to detect an abnormality, yet specific enough to
avoid the chances of over‐diagnosis. The prevalence
of the disease or condition being looked for is likely
to be low in a healthy asymptomatic patient popula-
tion. Thus, most tests are likely to be within the nor-
mal range. Inappropriate and excessive tests increase
the likelihood of a false‐positive result due to chance.
With extensive multiphasic screening profiles of
healthy individuals, about 5% of healthy normal
people will show one abnormal result.
1: Preoperative management 5
Evaluation of the elderly
asymptomatic patient
Ageing increases the likelihood of asymptomatic
conditions and screening investigations are therefore
more stringently applied to older, apparently healthy
patients. Elderly patients (aged over 70 years) have
increased mortality and complication rates for surgi-
cal procedures compared with young patients.
Problems are related to reduced functional reserve,
coexisting cardiac and pulmonary disease, renal
impairment, poor tolerance of blood loss and greater
sensitivity to analgesics, sedatives and anaesthetic
agents.
Complications of atelectasis, myocardial infarc-
tion, arrhythmias and heart failure, pulmonary
emboli, infection and nutritional and metabolic
­disorders are all more frequent. Separation of the
effects of ageing, frailty and of associated diseases
is difficult. Most of the increased mortality and
morbidity is due to associated disease.
Special attention needs to be paid to the assess-
ment of cardiac, respiratory, renal and hepatic func-
tion along with patient frailty before operation in
elderly patients.
Patient safety (see also Chapter 12)
Once in hospital, and particularly once under
anaesthetic, patients rely upon the systems and
­policies of individuals and healthcare institutions
to minimise the risk of inadvertent harm. Whilst
every hospital will have slightly different policies
the fundamental goals of these include the
following.
• The correct patient gets the correct operation on
the correct side or part of their body. An appro-
priate method of patient identification and
patient marking must be in place. It must be clear
to all involved in the procedure, particularly for
operations on paired limbs or organs when the
incorrect side could be operated upon.
• The patient is protected from harm whilst under
anaesthetic. When under a general anaesthetic
the patient is vulnerable to a number of risks.
Important amongst these are pressure effects on
nerves, for example those on the common pero-
neal nerve as it winds around the head of the
fibula.
• Previous medical problems and allergies are iden-
tified and acted upon.
• Protocols for the prevention of perioperative
infection and venous thromboembolism are
followed.
6 Principles of Surgery
Prophylaxis
Infection
Infections remain a major issue for all surgical
procedures and the team caring for the patient
­ Factors related to both the patient and the
needs to be aware of relevant risks and act to
­minimise such risks.
Before discussing the use of prophylactic antibiot-
ics for the prevention of perioperative infection, it is
very important that issues of basic hygiene are dis-
cussed (see also Chapters 9 and 12). Simple measures
adopted by all those involved in patient care can
make a real difference to reducing the risk of hospi-
tal‐acquired infection. The very widespread and sig-
nificant problems with antibiotic‐resistant organisms
such as meticillin‐resistant Staphylococcus aureus
(MRSA) and vancomycin‐resistant Enterococcus
faecalis (VRE) have reinforced the need for such
basic measures.
• Wash your hands in between seeing each and
every patient.
• Wear gloves for removing/changing dressings.
• Ensure that the hospital environment is as clean
as possible.
These measures, especially hand hygiene, should be
embedded into the psyche of all those involved in
patient care.
In addition to the very important matters of
hygiene and appropriate sterile practice, antibiotics
should be used in certain circumstances to reduce
the risk of perioperative surgical site infection. Each
hospital will have individual policies on which par-
ticular antibiotics to use in the prophylactic setting
(see also Chapters 9 and 12). The antibiotics are
usually administered at or shortly before the induc-
tion of anaesthesia and continued for no more than
24 hours postoperatively. It is also important to
state that whilst the use of prophylactic antibiotics
Table 1.1 Risks of postoperative surgical site infection.
Type of procedure Definition
Clean No contamination; gastrointestinal,
genitourinary or respiratory tracts not
breached
Clean‐contaminated Gastrointestinal or respiratory tract
opened but without spillage
Contaminated Acute inflammation, infected urine, bile,
gross spillage from gastrointestinal tract
Dirty Established infection
can, when used appropriately, significantly reduce
infectious complications, inappropriate or pro-
longed use can leave the patient susceptible to
infection with antibiotic‐resistant organisms such
as MRSA or VRE.
planned procedure govern the appropriate use of
antibiotics in the prophylactic setting.
Patient‐related factors
Patients with immunosuppression and pre‐existing
implants and patients at risk for developing infec-
tive endocarditis must receive appropriate prophy-
laxis even when the procedure itself would not
indicate their use.
Procedure‐related factors
Table 1.1 indicates the risk of postoperative surgi-
cal site infections with and without the use of pro-
phylactic antibiotics. In addition to considering
the absolute risk of infection, the potential conse-
quences of infection must also be considered; for
example, a patient undergoing a vascular graft (a
clean procedure) must receive appropriate antibi-
otic cover because of the catastrophic consequences
of graft infection.
Venous thromboembolism
Deep vein thrombosis (DVT) is a not uncommon
and potentially catastrophic complication of sur-
gery. The risk for developing DVT ranges from a
fraction of 1% to 30% or greater depending on
both patient‐ and procedure‐related factors. Both
patient‐ and procedure‐related factors can be
­classified as low, medium or high risk (Table 1.2).
High‐risk patients undergoing high‐risk operations
will have a risk for DVT of up to 80% and a
Wound infection rate (%)
Without prophylactic With prophylactic
antibiotics antibiotics
1–5 0–1
10 1–2
20–30 10
40–50 10
 1: Preoperative management 7

Table 1.2 Prevention of deep vein thrombosis.

Operative risk factors

Low (e.g. hernia Medium (e.g. general High (e.g. pelvic cancer,
repair) abdominal surgery) orthopaedic surgery)

Patient risk Low (age <40, no No prophylaxis Heparin Heparin and mechanical
factors risk factors) devices
Medium (age >40, Heparin Heparin Heparin and mechanical
one risk factor) devices
High (age >40, Heparin and Heparin and Higher‐dose heparin,
multiple risk factors) mechanical devices mechanical devices mechanical devices

pulmonary embolism risk of 1–5% when prophy- in‐depth preoperative preparation. Whilst the prin-
laxis is not used. These risks can be reduced by at ciples already outlined are still valid, a number of
least one order of magnitude with appropriate additional issues are raised.
interventions.
Whilst a wide variety of agents have been trialled Informed consent
for the prevention of DVT, there are currently only
Whilst there is still a clear need to ensure that patients
three widely used methods.
are appropriately informed, there are fewer opportu-
• Graduated compression stockings: these stock-
nities to discuss the options and potential complica-
ings, which must be properly fitted, reduce
tions with the patient and their family. In addition,
venous pooling in the lower limbs and prevent
the disease process may have resulted in the patient
venous stagnation.
being confused. The team caring for the patient needs
• Mechanical calf compression devices: these work
to judge carefully the level of information required in
by intermittent pneumatic calf compression and
this situation. Although it is very important that fam-
thereby encourage venous return and reduce
ily members are kept informed, it has to be remem-
venous pooling.
bered that the team’s primary duty is towards the
• Heparin: this drug can be used in its conventional
patient. This sometimes puts the team in a difficult
unfractionated form or as one of the fractionated
position when the views of the patient’s family differ
low‐molecular‐weight derivatives. The fraction-
from those which the team caring for the patient
ated low‐molecular‐weight heparins offer the
hold. If such an occasion arises then careful discus-
convenience of once‐ or twice‐daily dosing for
sion and documentation of the decision‐making pro-
the majority of patients. It must however be
cess is vital. Increasingly, patients of very advanced
remembered that the anticoagulant effect of the
years are admitted acutely with a surgical problem in
low‐molecular‐weight heparins may not easily
the setting of significant additional medical prob-
be reversed, and where such reversal may be
lems. It is with this group of patients that specific
important, standard unfractionated heparin
ethical issues around consent and appropriateness of
should be used.
surgery occur. It is important that as full as possible a
The three methods are complementary and are
picture of the patient’s overall health and quality of
often used in combination, depending on the patient
life is obtained and that a full and frank discussion of
and operative risk factors (Table 1.2).
the options, risks and benefits takes place.
The systematic use of such measures is very
important if optimal benefit is to be gained by the
Preoperative resuscitation
potential reduction in DVT.
It is important that wherever possible significant
fluid deficits and electrolyte abnormalities are cor-
Preoperative care of the acute surgical rected prior to surgery. There is often a balance to
patient be made between timely operative intervention and
the degree of fluid resuscitation required. An early
A significant number of patients will present with discussion between surgeon, anaesthetist and, when
acute conditions requiring urgent or emergency required, intensivist can help plan the timing of sur-
surgical operations. There may be little time for an gical intervention.
8 Principles of Surgery
Pre‐existing medical comorbidities
There is clearly less time to address these issues and
it may not be possible to address significant ongo-
ing medical problems. Clearly such comorbidities
should be identified, and all involved with planning
the operation should be informed. The issues are
most acute for significant cardiac, respiratory,
hepatic or renal disease.
Preoperative nutrition
An awareness of the nutritional status of patients is
important and such awareness should guide the
decisions about nutritional support (see Chapter 7).
The well‐nourished adult patient should be fasted
for at least 6 hours prior to anaesthesia to minimise
the risk of aspiration. Where possible regular medi-
cations, especially those for cardiovascular and res-
piratory conditions, should be continued.
Before an operation the malnourished patient
should, whenever possible, be given appropriate
nutritional support. There is no doubt that signifi-
cant preoperative malnutrition increases the risk of
postoperative complications (>10–15% weight
loss). If possible, such nutrition should be given
enterally, reserving parenteral nutrition for the
minority of patients in whom the gastrointestinal
tract is not an option. Parenteral nutrition is associ-
ated with increased costs and complications and is
of proven benefit only in the seriously malnour-
ished patient, when it should be given for at least
10 days prior to surgery for any benefits to be seen.
There is increasing evidence that enteral feeds spe-
cifically formulated to boost certain immune
parameters offer clinical benefits for patients about
to undergo major surgery.
After operation any patient who is unable to take
in normal diet for 7 days or more should receive
nutritional support, which as before operation
should use the enteral route whenever possible.
Specific preoperative issues
Allergies
A history of adverse or allergic reactions to medica-
tions or other substances must be documented and
repeat administration and/or exposure avoided as a
life‐threatening anaphylaxis may result. Examples
of allergens within surgical practice include antibi-
otics, skin preparations (e.g. iodine), wound dress-
ing adhesives and latex. A complete latex‐free
environment is required for those patients with a
known latex allergy.
Diabetes mellitus
Diabetes mellitus is one of the most frequently seen
medical comorbidities that complicate periopera-
tive care. It is clearly important that patients with
diabetes mellitus are appropriately worked up for
surgery.
In the weeks leading up to elective surgery the
management of the diabetes should be reviewed
and blood glucose control optimised. Particular
attention should be paid to HbA1c levels as an
index of diabetic control as well as cardiovascular
and renal comorbidities during the preoperative
assessment.
Generally, patients with diabetes should be
scheduled for surgery first case in the morning.
Diet‐controlled patients require no special preop-
erative preparation. For patients taking oral hypo-
glycaemic drugs, the drugs should be stopped the
night before surgery and the blood glucose moni-
tored. Patients with insulin‐dependent diabetes
should receive a reduced dose of insulin and/or a
shorter‐acting insulin or be commenced on an
intravenous insulin infusion. There are two
approaches to this.
• Variable‐rate insulin infusion: the patient’s blood
glucose levels are monitored regularly and the
rate of insulin infusion adjusted. An infusion of
dextrose is continued throughout the period of
insulin infusion.
• Single infusion of glucose, insulin and potassium
(GIK): whilst this method has the advantage of
simplicity, it is not possible to adjust the rates of
glucose and insulin infusion separately and the
technique can lead to the administration of exces-
sive amounts of free water.
The variable‐rate infusion is the most widespread
approach and although more involved in terms of
monitoring offers better glycaemic control. This in
itself is associated with better patient outcomes.
Cardiac disease
Surgical risk is increased in the presence of cardiac
disease. Consideration must be given to balancing
the risk to the patient if the procedure is abandoned
or delayed with the additional risk caused by the
presence of cardiac disease. Emergency operations
for life‐threatening conditions should proceed
regardless but elective surgery should be deferred in
the presence of recent‐onset angina, unstable
angina, recent myocardial infarction, severe aortic
valve stenosis, high‐degree atrioventricular block,
severe hypertension and untreated congestive car-
diac failure. Time should be spent investigating the
condition and optimising therapy, frequently with

cardiological assistance. The introduction of beta‐
blocker therapy to slow heart rate and occasionally
myocardial revascularisation (by percutaneous
coronary intervention or coronary artery bypass
­ Additional respiratory preparation may include
grafting) may be required in advance of surgery on
another system.
Anticoagulant or antiplatelet therapy
Patients on warfarin should be transferred to hepa-
rin or enoxaparin well in advance of surgery to
ensure that the warfarin effect has worn off.
Heparin can be ceased for a short time in the perio-
perative period: withhold an infusion 4 hours
before surgery and recommence once the risk of
postoperative bleeding is low. Subcutaneously
administered heparin or enoxaparin is withheld the
day or evening before surgery and recommenced
later that day or the day after. Warfarin recom-
mences once the patient can take oral medication.
Rapid reversal of warfarin prior to an emergency
operation may be achieved with vitamin K, pooled
fresh frozen plasma or clotting factors.
The new oral anticoagulants (dabigatran, apixa-
ban or rivaroxaban) are difficult to reverse acutely
and need to be ceased 2–5 days preoperatively. A
specific dabigatran reversal agent has recently
become available. A bridging regimen such as that
described above is also required.
The antiplatelet agents (aspirin, clopidogrel or
ticagrelor) taken alone or in combination should be
ceased at least 5 days prior to an operation. Bleeding
will be highly problematic at the time of surgery
especially if multiple antiplatelet agents are contin-
ued. Combined usage often follows coronary artery
stenting and so their withdrawal in the context of
surgery should be discussed with the treating inter-
ventional cardiologist. Elective surgery may need to
be postponed if dual antiplatelet therapy cannot be
safely ceased.
Active smoking and respiratory disease
All active smokers should be encouraged to cease
for at least 4 weeks in advance of elective surgery in
order to lessen the risk of respiratory problems
(atelectasis, acute pneumonia and respiratory fail-
ure) in the postoperative period. Patients unwilling
or incapable of stopping smoking should be referred
to a dedicated support service to assist with such.
Patients with chronic obstructive pulmonary dis-
ease (COPD), asthma and obstructive sleep apnoea
require a detailed respiratory assessment (including
peak flow, spirometry and arterial blood gas esti-
mation) especially if the patient reports significant
exercise limitation. Elective surgery should be
1: Preoperative management 9
deferred in the presence of an active respiratory
infection or an acute exacerbation of asthma or
COPD.
chest physiotherapy, postural drainage, antibiotics
for an acute infection with a positive sputum cul-
ture and inhaled bronchodilators or corticosteroid
therapy. A formal preoperative pulmonary rehabili-
tation program may be indicated. Regional anaes-
thesia is frequently preferred in patients with severe
respiratory dysfunction.
Long‐term corticosteroid therapy
Long‐term corticosteroid therapy results in adrenal
suppression and an impaired response to surgical
stress. High‐dose intravenous hydrocortisone
administration (100 or 250 mg every 6 hours) will
be required during the perioperative period and
when the patient is unable to take their regular
medication or in the presence of postoperative com-
plications especially infection.
Cerebrovascular disease
Stroke may complicate major surgery especially in
elderly patients with severe intracranial or extrac-
ranial atherosclerotic disease faced with fluctua-
tions in blood pressure or cerebral blood flow. An
asymptomatic carotid bruit related to an internal
carotid artery stenosis confirmed with Doppler
ultrasonography may be the first indicator of such
disease. Patients with symptomatic carotid disease
(e.g. transient ischaemic attacks) should undergo
carotid endarterectomy prior to the planned sur-
gery. However, there is no evidence that a prophy-
lactic carotid endarterectomy is of benefit in the
asymptomatic patient.
Chronic liver disease and obstructive
jaundice
Chronic liver disease of any cause may predispose
the patient to surgical complications such as poor
wound healing, sepsis, excessive bleeding, renal
impairment and acute delirium. Each of the previ-
ously discussed screening investigations will be
required in addition to specific liver and biliary tree
imaging and possibly liver biopsy. The decision to
operate on a patient with severe liver insufficiency
must be carefully considered. Elective surgery
should be deferred whilst liver function is opti-
mised. Emergency surgery can often result in
acute liver decompensation especially in the
­presence of sepsis, haemorrhage, electrolyte distur-
bances, hypoxia and hypoglycaemia.
10 Principles of Surgery
Patients with obstructive jaundice (see
Chapter 67) frequently have an abnormal coagula-
tion profile and require vitamin K, coagulation fac-
tors or pooled fresh frozen plasma to correct the
defect. Close attention needs to be paid to the
patient’s fluid and electrolyte status in order to pre-
vent acute renal failure. The hepatic clearance of
some commonly administered medications may be
impaired.
Chronic kidney disease
All patients aged over 40 years should have their
kidney function evaluated (urinalysis, serum creati-
nine, estimated glomerular filtration rate and
serum albumin) when major surgery is planned.
Documented chronic kidney disease does not man-
date deferral of elective surgery. Patients with
chronic kidney disease may experience an acute
deterioration in kidney function if they become
water or saline depleted. Acute kidney failure is the
most significant complication of chronic kidney
disease: prevention demands strict attention to
fluid and electrolyte balance (especially avoiding
dehydration and maintaining a stable level of serum
potassium), maintaining kidney perfusion and
accurate replacement of blood loss during surgery.
Apart from acute kidney failure, the main compli-
cations of surgery in patients with chronic kidney
disease are sepsis (including urinary tract infection),
poor wound healing and cardiovascular complica-
tions (myocardial infarction and stroke).
Anaemia
As a general rule mild anaemia does not increase
the risk of surgery. However, if time permits the
cause of the anaemia should be identified before
elective surgery. Iron deficiency anaemia is best
detected early and treated by oral or intravenous
iron. Patients with the anaemia of renal injury are
an exception to the general rule and can cope with
quite low haemoglobin levels, due to an increase in
red cell 2,3‐diphosphoglycerate (2,3‐DPG) that
promotes better transfer of oxygen at the tissue
level. However, in all patients the combination of
any degree of anaemia with decompensated cardio-
vascular disease (e.g. angina or obstructive airways
disease) warns that intensive perioperative care will
be necessary.
Preoperative haemoglobin measurement should
be performed as a routine examination in all
patients. Patients may have significant anaemia but
no symptoms if the anaemia has developed slowly
over a period of months and the body has compen-
sated for the decreased oxygen‐carrying capacity
through such physiological mechanisms as
increased cardiac output. The signs and symptoms
of anaemia vary with its severity and are more
marked if the anaemia has developed over a short
period. Symptoms of weakness and tiredness,
breathlessness, palpitations and angina can occur
with moderate or severe anaemia. Pallor is the out-
standing physical sign. Pallor of the conjunctiva
and the palmar creases becomes apparent when the
haemoglobin level falls below 10 g/dL. Tachycardia
and cardiac failure may accompany severe anae-
mia. Patients with significant or symptomatic anae-
mia should be evaluated by a specialist physician or
haematologist, frequently in a dedicated anaemia
clinic.
In the surgical patient, it is often possible to insti-
tute iron therapy prior to admission to hospital.
Anaemia is thus always best diagnosed and its
cause determined during the first office consulta-
tion in patients needing elective surgery. For iron
deficiency anaemia caused by blood loss, oral iron
therapy begins immediately so that anaemia can be
safely corrected prior to surgery. Patients with mod-
erate iron deficiency or haemolytic anaemias do not
pose an excessive risk provided the haemoglobin
level and the blood volume are adequate (>10 g/dL)
and cardiorespiratory function is normal.
In patients with megaloblastic anaemia surgery
should be deferred, if possible, until specific therapy
such as vitamin B12 or folic acid has repaired the
generalised tissue defect. In these cases, transfusion
alone may not render surgery safe, as protein metab-
olism of all cells is affected by the vitamin deficiency
that causes the macrocytic anaemia. Adequate tissue
levels can be achieved with 1–2 weeks of oral treat-
ment with vitamin B12 or folic acid or both.
If it is not possible to correct the anaemia in a
timely manner, the patient may be given concen-
trated red cells prior to surgery. A period of 3 days
should be allowed to elapse before operation as the
transfused blood will not reach its maximum oxy-
gen‐carrying capacity until at least 2 days following
transfusion. This period allows the transfused red
cells to accumulate normal levels of 2,3‐DPG, nec-
essary for efficient delivery of oxygen to the tissues,
and allows plasma dispersal restoring normovolae-
mia. Elective surgery should seldom be undertaken
when the haemoglobin concentration is less than
9–10 g/dL. Patients with long‐standing anaemia are
able to tolerate a reduced level of haemoglobin bet-
ter than those who have become acutely anaemic.
This tolerance in chronic anaemia is a result of
altered 2,3‐DPG concentration in the red cells, with
a favourable shift in the oxyhaemoglobin dissocia-
tion curve to the right.
 1: Preoperative management 11

Woodhead K, Fudge L (eds) Manual of Perioperative Care:

Psychological preparation and mental an Eessential Guide. Oxford: Wiley Blackwell, 2012.
illness

All surgical patients must be in a relaxed state of MCQs

mind irrespective of the nature of the procedure
they are about to undergo. Anxiety and a fear Select the single correct answer to each question. The
of the unknown or of the potential complications correct answers can be found in the Answers section
of surgery are common, especially in the con- at the end of the book.
text of life‐threatening illnesses or procedures.
1 Without the use of prophylaxis the risk of deep calf
Reassurance can be achieved by empathetic sur-
vein thrombosis in a patient undergoing an anterior
geon communication with the patient and their
resection for rectal cancer is likely to be at least:
relatives and, in certain instances, by the provi-
a 10%
sion of specialised input from other healthcare
b 20%
professionals such as support nurses or
c 30%
psychologists.
d 50%
Patients with pre‐existing mental illness such as
anxiety, depression, psychoses, substance abuse or
2 Which of the following measures is most likely to
dementia who are preparing for an operation
reduce the risk of postoperative wound infection
require guidance from their treating healthcare pro-
with MRSA?
fessionals such that their condition is optimally
a 5 days of broad‐spectrum prophylactic antibiotics
managed in the perioperative period. The stress of
b ensuring the patient showers with chlorhexidine
surgery may worsen or unmask any pre‐existing
wash prior to surgery
mental condition. Care must be taken in the pre-
c a policy of staff hand washing between patients
scription of analgesics, anxiolytics, sedatives, anti-
d screening patients for MRSA carriage prior to
depressant and antipsychotic medications in these
surgery
patients.

3 Which of the following constitutes the legal standard

Further reading
Smith JA, Yii MK. Pre-operative medical problems in sur-
gical patients. In: Smith JA, Fox JG, Saunder AC, Yii
MK (eds) Hunt and Marshall’s Clinical Problems in
Surgery, 3rd edn. Chatswood, NSW: Elsevier,
2016:348–70.
Wilson H. Pre-operative management. In: Falaschi P,
Marsh DR (eds) Orthogeriatrics. Springer International
Publishing, 2017:63–79.
for the information that should be passed to a patient
to meet the requirements of ‘informed consent’?
a what a patient in that position would regard as
reasonable
b what a reasoned body of medical opinion holds
as reasonable
c a list of all possible complications contained
within a patient explanatory brochure
d all serious complications that occur in more than
1% of patients
2 Assessment of surgical risk
Benjamin N.J. Thomson
University of Melbourne, Royal Melbourne Hospital Department of Surgery and Department of
General Surgery Specialties, Royal Melbourne Hospital, Melbourne, Victoria, Australia

For most surgical procedures the benefits of per-

Introduction forming surgery far outweigh the risks and the deci-
sion is easier, but for complex surgical procedures
This chapter reviews the assessment of risk for
the risks may outweigh any benefit. As outlined by
patients being considered for surgery or other inva-
the General Medical Council document the risks of
sive interventions.
not performing surgery also need to be considered.
Another important aspect is the likely outcome
from surgery. For example, most patients with ade-
Surgical risk
nocarcinoma of the head of the pancreas are not
suitable for surgical management due to the pres-
The definition of surgical risk is complex and dif-
ence of metastatic disease or involvement of the
fers depending on the point of view of the assessor.
major adjacent blood vessels. After appropriate
The risks of a particular surgical procedure may
preoperative staging only 5–10% of patients are
have a different value when considered by the sur-
suitable for surgery. Resection of the pancreatic
geon, anaesthetist, intensivist, patient or family
head (pancreaticoduodenectomy or Whipple’s pro-
member.
cedure) had a mortality of 50% in the 1950s,
What a surgeon may consider to be a small com-
whereas in 2018 the reported mortality in specialist
plication may be devastating to a patient depending
centres was 0.0–6.0%. Furthermore, operative
on their personal circumstances. For example, a
morbidity is close to 50%. Despite the high mor-
very rare risk of a unilateral recurrent laryngeal
bidity and mortality, the median survival for those
nerve injury leading to vocal cord palsy is well tol-
patients undergoing successful resection is only
erated by the majority of patients but is a disaster
14–24 months even in high‐volume centres. Clearly
for a professional singer. From a patient’s perspec-
any patient being considered for surgery needs also
tive surgical risk encompasses the mortality and
to understand the likelihood of successful treat-
morbidity relevant to their circumstances as well as
ment and to be able to balance this against their
the chance of successfully achieving the desired
own personal circumstances as well as the likeli-
outcome.
hood of morbidity and mortality.
The General Medical Council (GMC) of the UK
Another reason to assess surgical risk is identifica-
defines the risk of a proposed investigation or treat-
tion of high‐risk patients who may benefit from risk
ment using three criteria as well as the potential
reduction measures such as preoperative and intra-
outcome of taking no action (Box 2.1). This is an
operative optimisation as well as postoperative man-
integral component of the consent process required
agement in intensive care or high‐dependency units.
for each intervention or surgical procedure and
allows the patient and clinician to make a consen-
sual decision after considering the benefits of a pro-
cedure balanced against the associated risks. Assessment of surgical risk
However, there may be a number of treatment
options for each surgical pathology so the assess- There are three components to assessment of surgi-
ment of surgical risk also facilitates surgical cal risk. The first is the associated mortality and
decision‐making. morbidity of all surgical procedures. This can be

Textbook of Surgery, Fourth Edition. Edited by Julian A. Smith, Andrew H. Kaye, Christopher Christophi and Wendy A. Brown.
© 2020 John Wiley & Sons Ltd. Published 2020 by John Wiley & Sons Ltd.
13
14 Principles of Surgery
Box 2.1 GMC‐UK definition of risk
of investigation/treatment
1 Side effects
2 Complications
3 Failure of an intervention to achieve the desired
outcome
4 The potential outcome of taking no action
Source: https://www.gmc‐uk.org/ethical‐guidance/
ethical‐guidance‐for‐doctors/consent/part‐2‐making‐
decisions‐about‐investigations‐and‐treatment#paragraph‐28
obtained from multiple data sources that include
personal audit, hospital audit, regional health data
or specialty group audits. Furthermore, there is
extensive published data available detailing the mor-
tality and morbidity of surgical procedures or inter-
ventions, although this is often reflective of leading
high‐volume centres. Therefore, publications that
report pooled data from all possible sources may
offer a clearer representation of surgical risks. A
brief overview of surgical risk is outlined in Table 2.1.
The next two components of surgical risk assess-
ment involve both subjective and objective parame-
ters. Subjective assessment includes information taken
from the history and examination of a patient as well
as recognition of patterns, clinical experience and
intuition of the assessor. Often the experience of the
assessor in surgical practice may be pivotal in identify-
ing those patients at greater risk. Objective risk assess-
ment includes biochemical and haematological testing
as well as assessment of physiological function, par-
ticularly cardiac and respiratory function. Assessment
of comorbidities also plays a role. There are also many
risk prediction models and scoring systems available
that can be general or surgery specific.
Discussing the risks of surgery
The General Medical Council of the UK has pub-
lished guidance on the consent process and in par-
ticular on the discussion of the side effects,
Table 2.1 Overview of the morbidity and mortality of common surgical procedures.
Surgical procedure
Inguinal hernia repair
Appendicectomy
Laparoscopic cholecystectomy
Pancreaticoduodenectomy
Oesophagectomy
Coronary artery bypass grafting
complications and other risks of surgery or inter-
ventions. It details the need for clear, accurate infor-
mation about the risks of a proposed procedure
being presented in a way that the patient under-
stands to enable them to make an informed
­decision. It is important to understand the patient’s
views and preferences as well as the adverse out-
comes that they are most concerned about. It is
impossible to cover every possible side effect or
adverse outcome for each procedure but discussion
of the common adverse outcomes whether severe or
less serious is required as well as any possible
­serious adverse outcomes.
There are a number of resources available to aid
in the discussion, such as procedure‐specific infor-
mation pamphlets produced at a hospital level,
surgical regulatory authorities or government
­
agencies.
Risk scoring systems
Many tools have been developed to estimate both
mortality and morbidity rates for individual
patients prior to a surgical procedure or interven-
tion. Most are scoring systems that estimate risk for
all patients whilst others are specific for high‐risk
patients or particular surgical procedures or disci-
plines. Like all tools they only provide an estimated
risk and none are perfect. Most incorporate both
physiological and comorbid data selected from
large databases of patients. These have then been
analysed with regression techniques to identify the
key variables. Often a weighting is added to each of
the variables. Ideally these scoring systems should
be validated in multiple other centres to analyse
their usefulness for particular patient groups.
ASA
One of the first scoring systems developed was by
the American Society of Anesthesiologists (ASA) in
1963. It was a five‐point classification system for
assessment of a patient prior to surgery. It was
Morbidity (%) Mortality (%)
8–32 0–0.5
3.0–28.7 0.9–2.8
14.7–21.4 0.3
20–54 0–6.0
25–45 0.7–10.0
30 1.5–2.5

Table 2.2 American Society of Anesthesiologists
classification of mortality rates.
ASA rating Number Deaths (%)
1 92 227 0.001
2 367 161 0.002
3 195 829 0.028
4 45 118 0.304
5 353 6.232
1E 3 018 0.000
2E 12 188 0.033
3E 7 109 0.155
4E 5 000 3.280
5E 899 19.911
Source: Hopkins TJ, Raghunathan K, Barbeito A et al.
Associations between ASA physical status and
postoperative mortality at 48 h: a contemporary
dataset analysis compared to a historical cohort.
Perioper Med 2016;5:29.
subsequently revised with a sixth category coding
for emergency patients. It is a combination of sub-
jective anaesthetic opinion with an objective assess-
ment of the patient’s fitness for surgery. The
majority of hospitals and anaesthetists in Australia
use it routinely.
The ASA classification is as follows.
• ASA I: a normal healthy patient.
• ASA II: a patient with mild systemic disease.
• ASA III: a patient with severe systemic disease.
• ASA IV: a patient with severe systemic disease
that is a constant threat to life.
• ASA V: a moribund patient who is not expected
to survive without the operation.
• ASA VI: a declared brain‐dead patient whose
organs are being removed for donor purposes.
The coding for emergency patients is marked
with the addition of an E.
The ASA system correlates with mortality, as out-
lined in Table 2.2 that details the outcome of
732,704 patients.
APACHE
First introduced in 1979, the Acute Physiology And
Chronic Health Evaluation (APACHE) system was
developed to measure the severity of illness in inten-
sive care patients. It consisted of both acute physi-
ological abnormalities as well as a chronic health
evaluation measure. This was updated in 1985 with
APACHE II with a reduction in the physiological
values from 34 to 12 as well as adding a points
score for diminished physiological reserve due to
immune deficiency and ageing as well as chronic
cardiac, pulmonary, renal or liver disease. Further
2: Assessment of surgical risk 15
expansion and improvement in the prognostic esti-
mates led to the development of APACHE III.
APACHE was never designed to predict mortal-
ity in individual patients. Furthermore, the ability
to predict an individual’s probability of survival
depends upon response to therapy over time. The
APACHE system is predominantly a guide for
intensive care patients and therefore assessment of
critically ill patients rather than a guide for elective
surgery.
POSSUM
The Physiological and Operative Severity Score for
the enumeration of Mortality and morbidity
(POSSUM) was first described in 1991. Rather than
a system for intensive care patients it was designed
as a scoring system to estimate morbidity and mor-
tality following surgery. It provides a risk‐adjusted
prediction of outcome. It is the most widely used
surgical risk scoring system in the UK. Various
modifications have been described and validated
for colorectal, oesophagogastric and vascular
patient groups. The Portsmouth P‐POSSUM was
developed in 1998 and is now the most commonly
used in the UK.
Pre‐admission clinics
Pre‐admission clinics have been established for
more than 20 years. They have many different roles
that include administration, surgical clerking, con-
sent, preoperative education as well as anaesthetic
review. They provide an excellent environment for
assessing surgical risk as well as for optimising
patients’ medical conditions prior to surgery. There
are very few studies assessing the efficacy of pre‐
admission clinics in determining a patient’s fitness
but there are studies demonstrating increased
patient satisfaction as well as a decrease in hospital
length of stay.
Risk scoring systems lack sensitivity and specific-
ity when applied to individuals. Assessment by an
anaesthetist in a pre‐admission clinic allows any
scoring system to be used as an adjunct to informa-
tion obtained through clinical assessment of each
individual patient. The three objectives of an anaes-
thetic preoperative assessment are firstly to identify
the risk of the patient developing an adverse out-
come. The second is to assess any comorbidities
that may be optimised prior to surgery. The third
objective is to individualise perioperative manage-
ment to attempt to minimise any remaining adverse
outcomes.
16 Principles of Surgery
There are a number of common comorbidities
that should be assessed to minimise surgical risk.
Cardiac disease
Ischaemic heart disease is the commonest cause of
serious cardiac adverse outcomes at the time of sur-
gery. There is a greater risk amongst patients with a
past history of myocardial infarction, particularly
within 3–6 months. The presence of angina is less
clear as a marker of increased risk but congestive
cardiac failure has consistently been found to be an
indicator of worse outcomes.
There are a number of investigations that can be
used to assess cardiac risk, the commonest being an
electrocardiogram. Non‐invasive assessments of
reversible cardiac ischaemia that may allow optimi-
sation prior to surgery include exercise electrocar-
diogram, radionuclide stress cardiac imaging and
stress echocardiography.
Respiratory disease
Patients with pulmonary disease are at risk of peri-
operative complications such as hyperreactive air-
ways, prolonged ventilation, atelectasis, pneumonia
and respiratory failure. The site of the surgical inci-
sion is important in determining risk due to impair-
ment of pulmonary function. Median sternotomy,
upper abdominal incisions and thoracotomy are
associated with the greatest risk.
Pulmonary function tests are the main investiga-
tion for assessment of pulmonary disease and treat-
ment of reversible airway disease may be required
prior to surgery.
Renal risk assessment
Acute renal failure after surgical procedures is
associated with a higher mortality rate. Many ter-
tiary referral hospitals also have large nephrology
services and surgical procedures on patients with
end‐stage renal failure are common. Again optimi-
sation of the biochemical consequences of renal
failure with preoperative renal dialysis is often
required for those patients with end‐stage renal
failure.
Hepatic risk assessment
There are a number of risk assessments for chronic
liver disease, including the Child–Pugh classifica-
tion and the Model for End‐stage Liver Disease
(MELD). Patients with liver failure are at a high
risk of death even following basic surgical proce-
dures so management in a specialist centre is
required to reduce the risk of an adverse outcome.
Neurological risk assessment
There are a number of risk factors for cerebrovas-
cular complications in the postoperative period
that include age, cerebrovascular disease, hyperten-
sion, atrial fibrillation and the type of surgery.
Haematological risk assessment
A past history of deep venous thrombosis, pulmo-
nary embolism or haematological disorders (i.e.
protein C and S deficiency) increases the risk of
thromboembolism in the postoperative period.
Operative risk in the elderly
Operative risk is greater in the elderly, with a two to
five times greater risk of death in comparison with
younger patients. In general, elderly patients have a
lower reserve when challenged by a surgical procedure
or complication. In the original National Confidential
Enquiry into Patient Outcome and Death (NCEPOD)
released in 1987, 79% of perioperative deaths
occurred in the over‐65 age group, although that only
represented 22% of the surgical population.
Summary
Assessment of surgical risk is a key component to
both preoperative surgical and anaesthetic care.
The assessment of surgical risk is critical in provid-
ing consent as well as for identifying those at risk
who can be optimised prior to surgery or managed
in an appropriate environment to allow for the best
possible outcome.
Further reading
Burnand KG, Young AE, Lucas J, Rowlands BJ, Scholefield J
(eds) The New Aird’s Companion in Surgical Studies,
3rd edn. Edinburgh: Elsevier Churchill Livingstone, 2005.
Paterson‐Brown S (ed.) A Companion to Specialist
Surgical Practice: Core Topics in General and
Emergency Surgery, 6th edn. Edinburgh: Elsevier, 2018.
MCQs
Select the single most appropriate answer to each
question. The correct answers can be found in the
Answers section at the end of the book.
1 Discussion of the risks of a surgical procedure
should include:
a the side effects
b likely complications

c failure of the proposed surgery to achieve the
desired outcome
d the potential outcome if no action is taken
e all of the above
2 The American Society of Anesthesiologists (ASA)
risk scoring system:
a consists of 12 acute physiological abnormalities
as well as a chronic health evaluation measure
b was designed for assessment of critically ill
intensive care patients
c can be adjusted according to various different
surgical procedures
d is a 6‐point classification system for assessment
of patients prior to surgery
e is assessed by the surgical team prior to surgery
3 Optimisation of cardiac ischaemia prior to surgery:
a is not necessary as ischaemic heart disease does
not increase operative risk
2: Assessment of surgical risk 17
b can be adequately assessed by electrocardiogra-
phy alone
c is not required if the patient continues to smoke
d is only required for high‐risk cardiac surgical
patients
e may involve assessment of reversible cardiac
ischaemia with radionuclide stress cardiac
imaging or stress echocardiography
4 Operative risk in patients over 65 years of age is:
a no greater than for younger patients
b dependent on regular aspirin intake
c greater than younger patients
d only a greater risk if surgery is required for
trauma
e greater for procedures performed under local
anaesthesia rather than general anaesthesia
Another random document with
no related content on Scribd:
„Waar komt gij vandaan?” waagde de man te vragen.

„Van den hemel”, sprak Raffles lachend, „van den hemel, waaraan gij
maling hebt, waarover gij vol minachting hebt gesproken tegen zekere
jonge dame.”

„Wie zijt gij?” hijgde de oude vrek op bijna onhoorbaren toon.

Een scherpe blik van Raffles trof hem, een dier blikken, waarvan Charly
Brand beweerde, dat zij leeuwen en tijgers konden hypnotiseeren.

Terwijl de oude man vol angst in elkaar dook, sprak de groote

onbekende:

„Ik ben Raffles!”

De grijsaard hief doodelijk verschrikt de handen op; hij wilde spreken,

maar kon geen geluid te voorschijn brengen.

De naam Raffles ontnam hem het laatste restje van zijn moed.

„Ik zie”, sprak Lord Lister, „dat gij een hebzuchtige oude vrek zijt, dat de
zucht naar geld u van uw verstand heeft beroofd.

„Dergelijke creaturen zijn voor mij de walgelijkste schepsels, die er

kunnen bestaan. Het zijn menschen, die voor niets deugen, die in hun
hartstocht gelijk staan met krankzinnigen en voor wie een inrichting als
die van Dr. Braddon een uitmuntend verblijf zou zijn.”

Als door een zweepslag getroffen, kromp de oude bij liet hooren van den
naam Braddon in elkaar.

Raffles bemerkte het; hij legde de revolver op zijn knieën, stak een
sigarette aan en sprak, terwijl hij rookte, op korten en beslisten toon tot
den ouden man:
„Ik geloof, mijn waarde, dat u meer aan uw leven gelegen is dan aan uw
geld; ik stel u nu voor de keus: òf gij schrijft een door mij gedicteerde
verklaring, òf — — —”

Glimlachend nam Raffles de revolver weer in de hand en hield die den

oude vlak voor zijn oogen, zoodat de opening van den loop diens
voorhoofd aanraakte.

„Dus—wilt gij de verklaring op papier zetten?”

„Ja”, hijgde de oude met trillende lippen.

„Goed”, antwoordde Raffles op kalmen toon. „Hier op tafel zie ik papier,

pen en inkt. Schrijf maar op.”

Raffles dicteerde en sidderend gehoorzaamde de oude man:

„Bij dezen verklaar ik, dat ik mijn stiefzoon in het krankzinnigengesticht van Dr.
Braddon heb laten opsluiten, om mij zijn vermogen toe te eigenen.”

„Zet uw naam er onder”, beval Raffles.

Ook dit deed de oude en Raffles las:

„James Eliot.”

Nu nam de groote onbekende de verklaring op en stak het schrijven in

zijn borstzak.

„Gij zijt een schurk!” sprak hij nu tot den ouden vrek, „gij verdient de
galg.

„Opdat gij echter, nadat ik vertrokken ben, geen verdere misdaden zult
plegen om in het bezit te komen van het geld, dat u niet toebehoort, zal
ik het voorzichtigheidshalve voorloopig bewaren.”
De vrek begon zacht te weeklagen, toen hij zag, hoe Raffles het geld
telde en in een kistje legde, dat hij afsloot.

„Het is tweehonderddertig duizend pond sterling”, sprak hij en hij schreef

een kwitantie tot dat bedrag, die hij den oude gaf.

Daarop nam hij het kistje, stak een nieuwe sigarette aan en wendde zich
nogmaals tot den man, die als verlamd op zijn stoel zat.

„Ik wensch u goeden nacht, mijnheer. Ik maak er u opmerkzaam op, dat,

in geval gij alarm mocht maken, dat in uw eigen nadeel zou zijn. [23]

„De verklaring, die gij mij hebt gegeven, is voldoende voor de politie.”

Reeds had Raffles de deur bereikt, toen hij bemerkte, dat hij had
vergeten, zijn revolver weer bij zich te steken.

Deze was op de schrijftafel blijven liggen.

Op hetzelfde oogenblik echter had ook de oude man dit gezien.

Met een haastige beweging greep hij het wapen, richtte het op Raffles
en riep:

„Blijf staan, schurk, of ik schiet.”

Raffles keek den opgewonden oude kalm glimlachend aan.

„Gij vergist u, Sir”, antwoordde hij op deze bedreiging, „dat wapen laat ik
hier als aandenken achter. Als gij er iemand mee wilt raken, moet gij het
eerst laden.

„Onthoud, dat John Raffles nog nooit met een revolver op een mensch
heeft geschoten en dat hij het ook nooit zal doen. Het wapen maakt den
man niet, maar hij, die het in handen heeft, is de gevaarlijkste
tegenstander van beiden. En nu nogmaals goeden nacht, Sir.”
Deze met groote kalmte uitgesproken woorden verbaasden den ouden
man.

Hij wilde zich overtuigen, of de revolver geladen was. Daartoe draaide hij
het wapen om en keek in den mond. Tegelijkertijd moesten zijn vingers
onwillekeurig den haan hebben aangeraakt.

Een schot knalde en, in het voorhoofd getroffen, zonk de oude gierigaard
voorover op den vloer.

Dadelijk werd het levendig in huis. Stemmen weerklonken door elkaar;

deuren werden open en dicht geslagen.

Raffles snelde haastig terug naar den ouden man, legde het geld weer
op tafel, de verklaring er naast en verliet het huis langs denzelfden weg,
waarlangs hij was gekomen.

Op straat nam de groote onbekende een rijtuig en beval den koetsier om

hem naar Hydepark te brengen.

Hij wilde nu met Lord Guildhall afrekenen. Hij kende dezen jongen man
uit de Sandwich-Club.

In de nabijheid van de villa aan het Hydepark, die er uitzag als een
vorstelijk paleis en die door den bankierszoon werd bewoond, liet Raffles
stilhouden en te voet begaf hij zich naar het huis.

Het was intusschen twee uur in den morgen geworden. Raffles wist zeer
goed, dat de Lord zelden voor drie of vier uur ’s nachts thuiskwam en op
deze wetenschap had hij zijn plan gebouwd.

Terwijl hij genoeglijk een sigaret rookte, wandelde hij met het grootste
geduld voor de villa heen en weer. Een tweede Browning-pistool hield hij
geladen in zijn zak gereed.
Hij had niet tevergeefs gewacht.

Het liep tegen drie uur, toen de auto van Lord Guildhall naderde en de
nachtbraker in halfbeschonken toestand uitstapte.

Hij verschrikte, toen Raffles uit het donker naar hem toekwam, zijn hoed
afnam en tot hem sprak:

„Goeden morgen, Lord Guildhall, ik heb hier al eenigen tijd op u gewacht

om een gewichtige zaak met u te bespreken.”

„Wie zijt gij?” vroeg Lord Guildhall verbaasd, terwijl hij den vreemdeling
vol wantrouwen van het hoofd tot de voeten bekeek.

„Een van de leden der Sandwich-Club”, antwoordde Raffles zeer gevat,

„ik had het groote genoegen, een week geleden een partij whist met u te
spelen. Wij spraken toen af elkaar terug te zullen zien. Daar mijn tijd tot
dusverre steeds in beslag was genomen heb ik nu, op dit ongewone uur,
op u gewacht.”

„Als ik mij goed herinner”, antwoordde Lord Guildhall, „dan heb ik de eer
met Mr. Van German te spreken.”

Onder dezen naam, dien van een Hollander, stond Raffles in de

Sandwich-Club bekend.

„Zeer juist”, antwoordde Raffles met een lichte [24]buiging, „ik ben
mijnheer Van German uit Amsterdam.”

Gedurende dit gesprek had de dienstdoende lakei het hek, dat den tuin
van de villa omgaf, geopend; hij stond nu met ontbloot hoofd vol eerbied
aan de deur.

„Mag ik u verzoeken met mij mee naar binnen te gaan?” sprak Lord
Guildhall, terwijl hij Raffles voorging het huis in.
In de studeerkamer van den Lord namen ze samen plaats; een oude
kamerdienaar zette op een Oostersch tafeltje mokka, sigaren en
sigaretten klaar.

„Laten wij het ons gemakkelijk maken”, zoo begon de gastheer. Bij die
woorden trok hij, zooals dat onder Engelsche gentlemen gewoonte is
wanneer zij onder elkaar zijn, zijn rok uit.

Daarop nam hij in onverschillige houding in een zachten fauteuil plaats,

strekte zijn beenen zoo ver mogelijk voor zich uit, gaapte meerdere
malen achter elkaar en slurpte langzaam een kop mokka.

Raffles volgde in alles zijn voorbeeld.

Nadat zij verscheidene minuten zwijgend tegenover elkaar hadden

gezeten, sprak Lord Guildhall:

„En nu ben ik zeer nieuwsgierig te vernemen, wat u in dit late uur of

liever gezegd zoo vroeg in den morgen, voor gewichtige zaken met mij
te bespreken hebt?”

„Zijt gij spiritist?”

„Wat?” lachte Lord Guildhall, „neen, mijn beste, aan dien onzin geloof ik
niet.”

„Maar ik wel,” antwoordde Raffles met ernstige stem, „en ik was

hedennacht op een spiritistische séance, waar ik merkwaardige dingen
hoorde, op u betrekking hebbende.”

Lord Guildhall werd onrustig. Met wantrouwende blikken keek hij den
bezoeker aan. Zou deze iets van zijn misdaad afweten?

Nadenkend stak de gastheer een sigaret aan om zijn stijgende onrust te

verbergen.
Nadat hij, om zich een houding te geven, zwijgend rookwolken om zich
heen had geblazen, sprak hij op schijnbaar onverschilligen toon:

„Vervloekt! Ik ben al blij, als de levenden mij met rust laten. Wat willen de
dooden van mij?”

„Dat zult gij dadelijk vernemen,” antwoordde Raffles. „De dooden hebben
dikwijls een groot conto met de levenden te verrekenen. Ik zelf ben een
goed medium en het is merkwaardig, dat ik dikwijls uitverkoren ben
geworden om de laatste wenschen van de afgestorvenen in vervulling te
brengen.”

„Praat toch geen onzin, dat is immers dwaasheid! Ik geloof niet aan
zulke vuile toovenarij!” riep Lord Guildhall op bruusken toon.

Raffles stond op, keek den Lord met een doordringenden blik van het
hoofd tot de voeten aan en antwoordde op scherpen toon, den nadruk
leggende op ieder woord:

„Ik hoop, Lord Guildhall, dat gij niet vergeet, dat wij beiden gentlemen
zijn. Ik verzoek u, de zooeven gesproken woorden met de noodige
verontschuldigingen terug te nemen. Anders.…”

Lord Guildhall, wien de zaak zeer onaangenaam begon te worden, en

wiens onzuiver geweten in Raffles een vijand vermoedde, stond
eveneens op en sprak:

„Als Lord Guildhall ben ik gewend, nooit mijn woorden terug te nemen,
zelfs niet voor den koning van Engeland! Vóór ik hiertoe overga, brengt
mijn overtuiging mij liever op het schavot.”

„Of aan de galg,” antwoordde Raffles op koelen toon.

Beide mannen namen elkaar op met flikkerende oogen.

„Hoe meent gij dat?” vroeg de Lord vorschend.

„Hoe ik dat meen?” sprak Raffles, „mij dunkt, dat ik duidelijk genoeg heb
gesproken. Ik heb beweerd, dat gij ten slotte ook nog wel eens aan de
galg zoudt kunnen komen.”

„Sir,” sprak Lord Guildhall, ziedend van toorn, „voor dat woord verlang ik
rekenschap van u.”

Raffles had zijn armen gekruist over de borst en [25]keek Lord Guildhall
met een kouden, ironischen blik aan. Hoon en verachting lag in zijn
stem, toen hij sprak:

„Zeer zeker! Wanneer ik deze woorden had gesproken tot een

gentleman, die in mijn oogen waard was om met hem te duelleeren. —
—

„Maar,” hij maakte een korte pauze en trad een schrede nader op Lord
Guildhall toe, zoodat hij bijna vlak voor dezen stond, „men vecht niet met
een mensch, wiens handen bevlekt zijn met het bloed van zijn broeder.”

Met doodsbleek gelaat wankelde Lord Guildhall achteruit, naar steun

zoekende.

„Gij liegt!” hijgde hij met moeite, in een zetel neervallende.

„No Sir,” antwoordde Raffles met harde stem, „ik heb in mijn geheele
leven nog nimmer een leugen gesproken en ik sta hier vóór u om u
wegens den dood van uw broer en uwe zuster ter verantwoording te
roepen.

„Indien gij werkelijk nog een greintje eergevoel bezit, echt eergevoel,
zooals een Lord Guildhall dat behoort te hebben en niet de laffe
overmoed van een moordenaar, dan begeeft gij u naar gindsch
wapenrek, neemt een van de pistolen van uw vader er uit, zet die tegen
uw slaap en drukt af.

„Dan blijft gij er tenminste voor bewaard, dat in de annalen uwer familie
moet worden vermeld, hoe de laatste Lord Guildhall zijn leven heeft
gelaten aan de galg.”

De oogen van den jongen Lord puilden bijna uit zijn hoofd van vrees en
ontzetting, met starenden blik keek hij Raffles aan.

Al zijn moed was geweken onder het gewicht van deze beschuldiging,
welke Raffles hem naar het hoofd slingerde. Hij waagde het niet zich te
verdedigen.

Maar zijn lafheid en zijn lust om nog verder te blijven leven deden hem
een uitweg in deze netelige zaak bedenken.

Een verraderlijke blik vloog uit zijn oogen naar Raffles, daarop keek hij
naar het wapenrek, dat tegen een der muren van de kamer stond.

„Gij hebt gelijk,” sprak hij, „ik zal doen wat gij verlangt.”

Met wankelende schreden begaf hij zich naar het wapenrek en greep
een duelleer-pistool.

Zoodra hij dit in handen had draaide hij zich met een ruk naar Raffles
toe, hield hem het wapen voor en riep uit:

„Sterf, afperser.”

Maar Raffles was hierop voorbereid geweest!

Bliksemsnel trok hij zijn hand uit den zak; Lord Guildhall zag den mond
van een Browning-pistool op zich gericht, nog voordat hij zijn wapen had
kunnen afschieten.

Verscheiden seconden stonden de mannen sprakeloos tegenover

elkaar.

Toen sprak Raffles met minachting:

„Foei, duivel! Gij zijt een vervloekte lafaard. Opdat gij echter zult weten,
dat mijn dood u niet zal baten deel ik u mee, dat mijn bediende de
opdracht heeft om de bewijsstukken van uw schuld, die ik verzameld en
schriftelijk gedeponeerd heb, hedenochtend aan den politie-inspecteur
Baxter van Scotland Yard ter hand te stellen, wanneer ik niet terug
mocht keeren.

„Ik geef u nog twee minuten den tijd, uw wapenschild voor het oog der
wereld rein te houden. Richt u daarnaar!”

Het koude angstzweet kwam Lord Guildhall op het voorhoofd. Hij liet zijn
wapen zakken en fluisterde met heesche stem:

„Misschien is er nog een andere weg om met u tot een vergelijk te

komen.”

„En welke dan?” vroeg Raffles.

„Ik zal u mijn geheele vermogen, mijn kasteelen en bezittingen

vermaken en vertrek zelf naar Amerika.” [26]

Raffles dacht even na en zei toen:

„Ik zie, dat u aan uw leven meer gelegen ligt dan dan uw eer!

„Zoo iemand heeft niet het recht, zich aristocraat te noemen. Ik doe u het
volgende voorstel:

„Gij schenkt uw geheele vermogen aan de stad Londen met het doel,
daarvoor een tehuis voor ouderlooze en buitenechtelijke kinderen te
stichten.

„Het bestuur daarvan mag niet aan een kerkelijke gemeente worden
opgedragen, maar een vrijmetselaarsloge zal de zaak in handen nemen.

„Onder deze voorwaarde zie ik van den kogel af; de eer van uw
wapenschild kunt gij op geen manier meer redden. Gij moogt in Amerika
uw leven eindigen aan de galg, zooals personen van uw slag gewoonlijk
hun loopbaan eindigen.
„Kunt gij u met dit voorstel vereenigen?”

„Jawel, dat kan ik,” zuchtte Lord Guildhall.

„Goed,” antwoordde de groote onbekende. „Ik verwacht u morgen om

tien uur precies bij notaris Tyler, Strand 111.

„Komt gij niet, dan zijt gij een uur later een gevangene.”

Voordat Lord Guildhall tijd had om iets te antwoorden, had Raffles de

kamer reeds verlaten en was na een paar minuten uit het huis
verdwenen. [27]

[Inhoud]
ZESDE HOOFDSTUK.
 DE INVAL IN HET KRANKZINNIGENGESTICHT.

Het was nog vroeg in den morgen in de reuzenstad.

Zooals het aanzwellen van een zeegolf, begon het drukke leven in de
straten van Londen.

Te midden van het geweldige lawaai klonk de schelle roep van de eerste
courantenverkoopers, die in alle mogelijke toonaarden uitriepen:

„Politie-inspecteur Baxter van Scotland Yard spoorloos verdwenen!

„Een geheimzinnige misdaad!

„Sedert vijf dagen ontvoerd!”

Toen Raffles dit bericht van Charly Brand vernam, kleedde hij zich
haastig aan en zei lachend tot zijn vriend:

„Ik zal aan de menschen in Scotland Yard een vingerwijzing doen

toekomen, die de grap gekruid zal maken.”

Hij liep naar de telefoon en liet zich met Scotland Yard aansluiten.

„Hier detective Marholm, Scotland Yard,” meldde zich het hoofdbureau.

„Hier uw oude bekende, John Raffles,” antwoordde Lord Lister met

innerlijke vreugde.

Beiden konden zij den wederzijdschen glimlach niet zien, die op hun
gezicht lag uitgedrukt gedurende dit onderhoud aan de telefoon.

„Wat is er voor nieuws, John Raffles?” vroeg detective Marholm. „Hebt

gij misschien ontdekt, waar onze inspecteur van politie verborgen zit?”
„Ja, juist,” sprak de groote onbekende, vroolijk lachend, „ik heb hem
eens naar buiten gezonden.”

„Duivelsch!” riep detective Marholm uit, „wij hebben gisteren van zijn
familie vernomen, dat onze hooggeachte chef spoorloos verdwenen is.
Ik zei juist al tot mijn collega’s: daar zit John Raffles zeker weer achter.”

„Ongetwijfeld!” gaf Lord Lister lachend ten antwoord. „Gisteren nog heb
ik met uw inspecteur gesproken; hij smeekte me, hem te stelen.”

„Wat?” riep detective Marholm uit, „dat begrijp ik niet.”

„Baxter zal u dit alles verklaren,” antwoordde Raffles, „het is, zooals ik u
zeg.

„Maar in weerwil van al mijn vaardigheid, was het mij niet mogelijk, aan
zijn verzoek te voldoen. Ik zal u echter thans vertellen, waar de
inspecteur van politie te vinden is.”

„Heel graag!”

„Neem verscheiden van de beste beambten van Scotland Yard en rijd

dadelijk met hen naar dr. Braddon, den gekkenkoning.”

„Braddon?” vroeg detective Marholm verbaasd, „Braddon? De dokter

telefoneerde een uur geleden, dat bij hem de brandkast voor eenige
duizenden pond sterling in den afgeloopen nacht was beroofd.”

„Hoe hoog is dat bedrag?” vroeg Raffles.

„Dat heb ik nog niet kunnen vaststellen,” antwoordde detective Marholm.

„Ik zal het u precies zeggen,” antwoordde de Groote Onbekende in de

telefoon, „het waren een onnoozele zevenduizend pond, acht shilling en
zes pence!” [28]
„Voor den duivel,” klonk het terug, „gij weet het bedrag zoo precies, alsof
ge het zelf hadt weggenomen.”

„Jawel,” antwoordde Raffles, „dat komt uit. Ik nam het geld mee als
belooning voor twee dagen werk, die ik bij dr. Braddon als verpleger heb
doorgebracht.”

„Zijt gij krankzinnigenverpleger geweest bij dr. Braddon?” vroeg Marholm

verbaasd.

„Waarom niet?” lachte Raffles, „’t is altijd nog beter in die inrichting
verpleger te zijn dan patiënt.”

„Best mogelijk,” luidde het antwoord van Scotland Yard, „maar vertel mij
nu toch om Godswil, waar zit inspecteur Baxter?”

„Bij dr. Braddon,” antwoordde Raffles. „Waar zou hij anders zijn? Hij
bevindt zich in het krankzinnigengesticht als patiënt.”

„Daar begrijp ik niets van,” antwoordde Marholm verbaasd.

„Maar ik wel,” sprak Raffles; „en ik zal het u uitleggen:

„De inspecteur van politie Baxter is door mij persoonlijk, terwijl ik mij
uitgaf voor professor Stanhope, in het gesticht van dr. Braddon gebracht
als zijnde mijn krankzinnige broer.

„Ik deed dat met de bedoeling, dat Baxter zich in zijne qualiteit van
detective op de hoogte kon stellen van de toestanden in dat
moordenaarshol, door zelf te zien en te ondervinden, hoe de patiënten
er behandeld worden.

„Ik herhaal: Neem den grootsten politiewagen en eenige doktoren mee,

en bereid bovendien verscheiden ziekenhuizen voor op de opname van
patiënten, want gij zult in dat krankzinnigengesticht zóóveel werk vinden
—en wel een zeer nuttig werk—als Scotland Yard nog hooit heeft gehad.
„Iedere dokter en iedere verpleger daar is rijp voor de galg. Zeer vele
van de patiënten moeten dadelijk onder dokters behandeling komen,
omdat zij door de onmenschelijke behandeling van dr. Braddon en zijn
handlangers in beklagenswaardigen toestand gebracht zijn!

„Opdat gij er volkomen van op de hoogte zijt, waar gij den inspecteur
van politie in de inrichting moet zoeken, deel ik u mede, dat hij zich
bevindt in den kelder van het hoofdgebouw naast de lijkenkamer, in
gezelschap van vier andere ongelukkige slachtoffers en aan den grond
vastgeketend.

„En nu haast u en groet inspecteur Baxter hartelijk van mij.”

Aan weerszijden werd de telefoonhoorn opgehangen. Het gesprek was

geëindigd.

Detective Marholm, die met klimmende verbazing en steeds grootere

verwondering had geluisterd, sprak tot zijn collega’s, nadat hij eindelijk
weer tot zich zelf was gekomen:

„Dat is de meest ongehoorde zaak, die ik ooit heb beleefd!

„Voorwaarts! Laten we onmiddellijk alles in gereedheid brengen om aan

den oproep van Raffles gevolg te geven! Onze inspecteur van politie ligt
als krankzinnig patiënt in de inrichting van dr. Braddon en wacht op ons!”

Detective Marholm, die door Raffles steeds als de bekwaamste van

geheel Scotland Yard werd beschouwd, nam zelf de leiding op zich om
de inrichting van dr. Braddon te overvallen.

In verscheiden wagens reed hij met een paar dozijn beambten naar de
buurt van het krankzinnigengesticht en liet daar de rijtuigen stilhouden.

Daarop begaf hij zich met vier beambten naar het gesticht.

Nadat de portier de zware ijzeren deur, zooals een tuchthuis ze niet

solieder kon bezitten, had geopend, verklaarde Marholm aan den
ontstelden beambte, terwijl hij zijn ambtspenning liet zien, dat deze zijn
gevangene was en bij de geringste poging om alarm te maken, of om
aan de detectives te ontvluchten, neergeschoten zou worden.

Marholm plaatste een zijner detectives naast den [29]portier, posteerde

een tweede bij de open poort en zond een derde naar de bij de rijtuigen
wachtende beambten met bevel om zich in het krankzinnigengesticht te
begeven.

Dit alles ging zoo snel, binnen een paar seconden, in zijn werk, dat noch
een portier, noch iemand anders uit de inrichting er iets van bemerkte.

Zoodra de detectives in het voorportaal bij elkaar waren, sprak Marholm

tot hen:

„Neemt uw revolvers in de hand en verdeelt u, zoo goed en zoo kwaad

als de plaatselijke kennis dit toelaat, over het geheele gesticht.

„Bezet alle trappen en portalen en verklaart iedereen, die het gebouw wil
verlaten, als uw gevangene, totdat ik nadere bevelen zal hebben
gegeven.”

Daarna stapte hij met de detectives, die hij voor mogelijke

noodzakelijkheid bij zich hield, de wachtkamer binnen.

Toen de daar aanwezige portier naar hun naam en hun verlangen vroeg,
sprak Marholm, wederom zijn ambtspenning vertoonend:

„Wij zijn ambtenaren van Scotland Yard en komen hier in verband met
den diefstal, die hier in den afgeloopen nacht werd gepleegd.”

„Ik zal het dadelijk aan dr. Braddon meedeelen,” antwoordde de portier
en verdween in de studeerkamer van zijn chef.

Reeds na een paar seconden kwam hij terug en sprak:

„Mijnheer de directeur laat u verzoeken, binnen te komen.”

Marholm en zijn begeleiders stapten naar binnen.

De gekkendokter zat nog in zijn chamber-cloack voor zijn schrijftafel; hij

ontving de ambtenaren met een mismoedig gelaat.

„U is dr. Braddon?” vroeg detective Marholm en keek den voor hem

zittende bij die woorden zeer scherp aan.

„Juist,” antwoordde deze en nam den detective zeer uit de hoogte op,
„spreek als ’t u belieft op een beleefden toon tot mij. Ik ben niet uw
ondergeschikte!”

„Maar mijn gevangene!” riep detective Marholm

Voordat dr. Braddon nog iets kon antwoorden, werd hij bij zijn armen
beetgepakt en geboeid.

„Help!” riep hij ontsteld uit en de portier, die dezen kreet om hulp hoorde,
snelde het studeervertrek binnen.

„Handen op!” beval Marholm en hield den man zijn revolver voor.

„Ik verklaar u mijn gevangene, wegens vermoedelijke medeplichtigheid

aan de misdaden van dr. Braddon. Wij zijn ambtenaren van Scotland
Yard!”

Sidderend van vrees bleef de portier midden in de kamer staan en

waagde het niet, zich te verroeren.

Marholm liet zijn collega’s als wacht bij dr. Braddon achter. Hijzelf begaf
zich op onderzoek naar het verblijf van den inspecteur van politie.

In de administratiekamer der inrichting, daar waar de brandkast stond,

hadden zich de beambten van het krankzinnigengesticht verzameld; zij
stonden schuw om den hoofdportier geschaard, toen Marholm
binnentrad.
„Wie van u,” vroeg de detective, „bezit de sleutels van alle vertrekken
der inrichting?”

Met knikkende knieën stapte de hoofdportier naar Marholm toe en

antwoordde:

„Ik ben de hoofdportier, wat wenscht gij?”

„Volg mij!” beval Marholm.

Hij begaf zich daarna, zooals Raffles hem had aangeduid, naar den
kelder en nam verscheiden van zijn beambten mee daarheen.

„Maak de deur open!” sprak hij, toen zij beneden waren gekomen.

Tegelijkertijd wees hij op een ingang, die naar het verblijf voerde, waarin
de inspecteur van politie en zijn vier ongelukkige lotgenooten lagen.

De hoofdportier draaide het electrische licht op en opende de deur.

In het volgende oogenblik trad Marholm de kelderruimte [30]binnen, doch

deinsde met een kreet van ontzetting terug bij den aanblik dien de
ongelukkigen boden.

Daarop snelde hij naar inspecteur Baxter toe, dien hij dadelijk had
herkend.

„Marholm!” riep deze verheugd uit, „zijt gij het werkelijk?”

„Ja,” antwoordde de trouwe detective met bleeke lippen, „John Raffles

zendt mij tot u.”

„Een edel mensch is hij, bij God een nobele kerel!” antwoordde
inspecteur Baxter met ontroerde stem.

„Ontdoe die ongelukkigen van hun boeien!” beval Marholm den

hoofdverpleger.
Deze gehoorzaamde aan zijn bevel, terwijl de beambten van Scotland
Yard hem behulpzaam waren.

Baxter was zóó zwak, dat hij op den arm van Marholm moest steunen,
toen deze hem naar boven bracht, terwijl de andere ongelukkigen
gedragen moesten worden.

Dr. Braddon staarde den inspecteur van politie aan alsof hij een
spookverschijning zag, toen deze met detective Marholm de kamer van
den geneesheer binnentrad.

„Kent gij dezen man?” vroeg Marholm den dokter, die met vaalbleek
gelaat in zijn stoel was gezonken.

„Jawel,” fluisterde hij met trillende stem, „het is een ongeneeslijke

patiënt, die wegens razernij in een aparte cel gebracht moest worden.”

„Schoft”, viel Baxter hem in de rede. „Erbarmelijke schoft. Ik ben de

Londensche inspecteur van politie en evenmin krankzinnig als de
ongelukkigen, die het hol met mij deelden.”

„Nu hoort ge het zelf,” sprak dr. Braddon. „Die man verbeeldt zich, dat hij
de inspecteur van politie van Londen is.”

„Neen”, antwoordde detective Marholm, „dezen keer zijt ge aan het

verkeerde adres gekomen. Deze zoogenaamde patiënt beeldt zich niets
in; hij is inderdaad de inspecteur van politie van Scotland Yard.

„Raffles—John Raffles—de Groote Onbekende—de meesterdief van

Londen, heeft, vermomd en onder den naam van professor Stanhope,
den inspecteur van politie in uwe inrichting gebracht, opdat hij zich
persoonlijk zou kunnen overtuigen van de ontzettende toestanden die
hier heerschen en van de schandelijke misdaden, die gij tot heden
ongestraft op de ongelukkige patiënten hebt kunnen plegen.”

„Raffles!” riepen bijna tegelijkertijd dr. Braddon en de inspecteur van

politie uit.